Ketamine assisted Psychotherapy
What is Ketamine? Ketamine is a dissociative anesthetic that was first synthesized in 1962. It’s primarily used for medical procedures that require anesthesia but don’t need muscle relaxation. Many people know it as a “horse tranquilizer.” This is due to it being more readily accessible in veterinary clinics. Ketamine doesn’t cause a complete loss of consciousness, but rather causes disassociation where the person feels disconnected from their body and environment.
What is ketamine therapy or ketamine assisted psychotherapy? KAP is a treatment approach that involves using ketamine prescribed by a medical doctor or nurse practitioner during psychotherapy sessions. Journey Clinical, the company that Life Works partners with, completes the medication assessment and prescribes Ketamine lozenges (or troches) that are shipped directly to the patient’s home. The client would then bring their ketamine into the office for a three-hour medication session. After the client takes their vitals, they self-administer the ketamine as recommended by their doctor. The amount taken during the medication session differs and again is based on their doctors' instructions. Some therapists talk about Ketamine being a great co-therapist, and this is a really good way to think of it. Ketamine helps to lower defenses and cognitive barriers in a way that clients can access and look at upsetting experiences without being overwhelmed. In traditional therapy, this could take a very long time and could actually be detrimental to the client. IV Ketamine clinics have been around for years. The biggest difference between those and KAP is the addition of a trained psychotherapist with whom you have a trusting working therapeutic relationship. Anyone who has tried to change a behavior knows how difficult that is and how many repetitions it takes to create new habits. This is primarily due to the fact that our brain operates by the principle of following the path of least resistance and will enact already established and reinforced neural pathways. Changing our behaviors and our responses to things requires the developement of new neural pathways. Research shows that having the support of a trained therapist supports the most beneficial and therapeutic impact. KAP also involves meeting with your therapist 24-48 hours after the medication session. This is appropriately called the integration session, as you’ll discuss and review what you experienced during the KAP session and the time afterward to reinforce the neural pathways that were created during the actual medication session. A typical round of KAP is 6-8 medication sessions with corresponding integration sessions. However, if appropriate, your prescribing physician or nurse practitioner could recommend that you continue KAP for more than 8 sessions.
How can ketamine help? Ketamine can help clients to experience an immediate reduction in symptoms of depression or anxiety that lasts for a couple of days to a couple of weeks. For those who have been diagnosed with PTSD, it can help to lower natural defenses that aim to protect us from re-experiencing traumatic memories or events. Avoiding trauma reminders can keep the person stuck in an endless feedback loop, which keeps the sympathetic nervous system stuck in fight or flight. When these defenses are lowered, the body can have the opportunity to process through to completion the trauma cycle and allow the parasympathetic nervous system to take over and shift the body out of fight or flight and into a state of calm or rest and digest.
How does ketamine work? What is ketamine like? Without getting too technical, the primary excitatory neurotransmitter in our brain is glutamate, while GABA is the primary inhibitory neurotransmitter. Glutamate is associated with processes such as learning, memory, and overall brain functioning. GABA helps to regulate and calm our brain down. A good metaphor is that glutamate is the gas and GABA is the brake. Ketamine acts on the NMDA receptors in our brain, which are ones that glutamate act on, so it helps to increase activity in our brain. Think about someone who is depressed. Their neural activity is suppressed. They tend to experience slowed thinking, have difficulty remembering and being excited about things (even things they’ve enjoyed in the past), and a lot of times have little to no energy or motivation. They might sleep a lot (or have difficulty sleeping). Ketamine activates the excitatory pathways and in general has rapid acting anti-depressant effects and demonstrates an anti-suicidal impact as well. Ketamine is believed to affect the brain in several ways: It reduces signals involved in inflammation. It causes physical growth in the prefrontal cortex. It increases the formation of new synapses in the brain. It facilitates communication in specific areas of the brain. It restores coordinated circuit activity. Ketamine can produce feelings of unreality, visual and sensory distortions, a distorted feeling about one’s body, temporary unusual thoughts and beliefs, and a euphoria or a buzz. It has a rapid action that diminishes physical sensation, prevents pain, induces sleep, and inhibits memory. In my experience, Ketamine has different effects on individuals. Some clients process trauma that’s been stuck in their body by having somatic experiences of pain. Some experience high levels of emotional distress. Some clients have only positive and expansive experiences. Some have spiritual experiences and feel connected to everything. Some have the sensation of floating in water and being rocked by gentle waves. Some experience significant relief with greater ability to regulate emotions, reduced symptoms, and changes in how they are dealing with and processing things. I’ve come to know that Ketamine always surprises.
What other conditions can ketamine assist with? Migraines? Chronic Pain? Neither Jordan nor I are medical doctors. Because individual responses to Ketamine can vary, it’s important to consult with your medical or prescribing doctor and other professionals on your care team to explore ketamine as an option for the issues we’ve discussed and other medical issues. As mentioned before, Ketamine has been shown to have strong anti-inflammatory properties, which can help to alleviate migraine-associated inflammation in the brain. This, in turn, may contribute to the reduction of migraine symptoms and frequency. According to a study done by the American Society of Anesthesiologists, 75% of the 61 people involved in the study reported an improvement in their migraine pain after receiving a ketamine infusion. Researchers at Thomas Jefferson University Hospital in Philadelphia studied 61 patients who received continuous three-day to seven-day treatment with ketamine and found that ketamine may provide some relief to patients for whom other drugs have been ineffective. Further studies are needed to investigate which people are best suited for the treatment. Many patients are reporting dramatic reduction in migraines after Ketamine infusions.
Is Ketamine FDA approved for depression? Spravato, the eskatamine nasal spray created by Janssen Pharmaceuticals, has been approved by the FDA for treatment resistant depression and may be covered by your insurance. IV, IM, Sublingual, or oral Ketamine has not been approved by the FDA for depression, anxiety, PTSD, or c-PTSD, so it’s considered off-label and isn’t covered by insurance. The difference between Ketamine and Spravato is that Ketamine is a racemic mixture composed of two molecules called R-ketamine and S-ketamine that spin in opposing directions. Esketamine is one-half of the ketamine molecule and is the S-enantiomer of ketamine. The two molecules have the same atoms in similar locations, but they are mirror images of each other.
What are the long term effects of ketamine? Can ketamine kill you? (Is ketamine dangerous?) Again, I want to remind everyone that neither Jordan nor I are medical doctor. Studies are still being conducted on the long-term results and benefits of ketamine use in the identified diagnosis categories. As is the case with any psychoactive substance or medication, there are risks associated with Ketamine use, including death if too much is taken. Ketamine administered at sub-anesthetic doses by infusion may result in several potentially harmful effects, most of which occur during the infusion period and resolve shortly thereafter. These can also occur with sublingual or oral administration. These acute and short-term effects include an increase in blood pressure (usually asymptomatic), nausea and vomiting, perceptual disturbance, drowsiness, dizziness, and dissociation. For KAP at my practice, my clients take their vitals, including blood pressure and heart rate before taking their prescribed ketamine and again near the end of the session to ensure they’re below the thresholds their prescribing doctor or NP determined before they leave my office. For sublingual ketamine, which is the route prescribed by Journey Clinical, the absorption rate is approximately 30% of the dose taken. Depending on the dose prescribed, one could have a full dissociative experience but is far less than the amount that would be prescribed for anesthetic purposes. It’s important to always discuss all other medications you are taking with your care provider, to not take any more Ketamine than is prescribed, and to not take it outside of the setting that it has been prescribed for. Ketamine has a 30-minute half-life elimination, so depending on the dose taken, the person may stop feeling the effects of the ketamine within an hour to an hour and a half. However, you are not allowed to drive for 6-12 hours after the dosing session.
What is a ketamine clinic like? What should I look for if I'm interested in trying ketamine therapy? This will vary by clinic. There are several ways that a client or patient can experience ketamine: IV, IM, or oral. For an IV or IM clinic, the setup might be more like a doctor’s office with a medical professional administering the Ketamine. At Life Works, clients come to our office and sit in a recliner, or if they’d prefer, they can lie on a mat on the floor with bolster pillows under their head/neck and knees. They are offered blankets, the use of essential oils to support what they are focusing on for their experience and are also given a choice of music that will be played for all or part of the three-hour medication session. Because choice is such an important aspect for all humans, and especially for trauma survivors, we allow clients who are doing individual KAP sessions to talk as much as they’d like during the experience. This helps them to feel connected and not alone, which are things that adult survivors of childhood abuse and neglect frequently experienced. You should look for a therapist who has completed training in providing Ketamine assisted psychotherapy. Ideally, also one that has either provided or shadowed KAP sessions and/or has experienced it for themselves. We have some screening paperwork that we send to interested clients before an initial session is scheduled, as there are some categories or diagnoses that are contraindicated for KAP. In general, these are a primary diagnosis of psychotic disorder, uncontrolled substance use disorder, uncontrolled hypertension/high bp, or acute mania, among others. That way, you haven’t committed the time and invested money into something you wouldn’t be able to do because of another condition. I’d also ultimately recommend working with someone who offers you the experience of being seen, heard, and validated in your initial sessions to determine if you are a suitable candidate. Emotional safety and the relationship matter.
