Ketamine Assisted Therapy
Is Ketamine Assisted Psychotherapy Right for Me?
Is Ketamine Assisted Psychotherapy right for me?
Why Ketamine Assisted Psychotherapy (KAP)?
Ketamine is a remarkable medicine that’s been used extensively in the US since the early 1970s. Like many medications it was designed for a specific purpose, and later discovered to be beneficial in other areas. Historically, ketamine has been used by anesthesiologists and emergency rooms as an anesthetic medication that doesn’t repress respiration or interact with many other medications. Ketamine is one of the safest and most widely used anesthetics in the world according to the World Health Organization.
Researchers at Yale have been studying low-dose ketamine since 2000 in controlled clinical settings for patients with severe depressive symptoms who are unresponsive to other antidepressants. In several studies, more than half show a significant decrease in depression symptoms in 24 hours and approximately 4 out of 5 went on to show significant improvement. Because of Yale’s efforts, ketamine was identified as a breakthrough medication for Treatment Resistant Depression (TRD) because unlike common antidepressants such as SSRIs that work on serotonin in the brain, ketamine operates in the GABAergic system of the brain. SSRIs have limited effectiveness for some people and can be less effective over time, so a medication that works in a different system of the brain has been life changing for those with TRD. Ketamine is now used extensively for many chronic mental health conditions including depression, suicidality, anxiety, anxious bipolar depression (without mania), post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), addictions, existential distress, and more.
Psychedelic or Psycholytic?
Psychedelic: When anesthesiologists discovered ketamine’s remarkable ability to eliminate suicidal ideation in some depressed patients quickly, they began to market it in a way that aligned with their professional backgrounds. Medical clinics for IV ketamine infusions began to open across the country. These clinics focused on the fast chemical antidepressant effect of the medicine and the “psychedelic” effects of ketamine were seen as a side effect which scientists have unsuccessfully sought to eliminate. Such clinics can still play a critical role for patients who are imminently suicidal and unaided by the older antidepressant medications. In these medical settings the patient is connected to an IV and infused with higher-dose ketamine for about 90 minutes. Because the focus is solely on the chemical benefit, psychotherapy is not provided during these treatments, and patients often experience the psychedelic effect of “ego dissolution” which can be scary and disorienting in the absence of experienced psychotherapeutic support.
Psycholytic: At Cohesive SOULutions™ we don’t offer higher-dose psychedelic ketamine infusions. Instead, we leverage the antidepressant elements of ketamine at a low dose (called psycholytic dosing) in conjunction with psychotherapy during the active phase of the medicine. We also provide Integration Therapy in between KAP sessions. The goal of psycholytic ketamine dosing is for clients to remain lucid and aware of themselves and their surroundings, thereby facilitating therapeutic conversations. Our approach takes advantage of the many other benefits* of ketamine which make it a life changing medication. What were originally seen as side effects, are now seen as essential benefits of ketamine which lead to healing, rather than just symptom reduction.
So, what are these “other *benefits”?
The advent of functional MRIs (fMRI) and improved brain scan technology have enabled researchers to study more about the psycholytic benefits of ketamine for mental health. The scientific community has uncovered some truly remarkable things:
Default Mode Network (DMN): The DMN consists of several areas of the brain that “wire together” when we’re forming our identity as children. These areas connect in a way that becomes more rigid with age. As the name implies, the DMN defines the default way in which we perceive reality and operate in the world including our perceptions of ourselves, self-criticism, and internally directed thoughts. Especially when this network is impacted by trauma, it tends to keep us stuck in non-creative ways of interfacing with the world. Ketamine softens the DMN during treatments and for at least 72 hours following treatment, which when combined with therapy, allows us to rewrite how we experience ourselves in the world! The process offers patients unprecedented insights and increased “psychological flexibility” while also providing a window in which to cement those changes in place as permanent, deep healing.
The activity of the DMN has been studied with fMRI imaging. In certain mental health conditions, such as depression, anxiety, and OCD, the DMN has been found to be overactive. Some experts have equated the overactive DMN with rigid thought patterns and negative thought loops. On ketamine, while the DMN activity is decreasing, connectivity in the rest of the brain outside of the DMN increases. When the activity of the DMN decreases the sense of self seems to shift and self-criticism and negative thought loops may decrease. Studies have demonstrated similarities to deep meditative states. In these states, increased activity occurs in pathways that typically don’t communicate. After these new pathways are formed it appears that the DMN becomes less isolated. It has been suggested that this may be one of the explanations for reduced depression and anxiety following ketamine journeys.
Neurogenesis: Ketamine has been shown to promote neurogenesis. That is, unlike the SSRIs which are temporary symptom-reducers, ketamine actually promotes healing. It’s been demonstrated using sophisticated brain imaging technology that people who suffer from chronic depression and anxiety experience atrophy (dying off) of neuronal connections in the brain. Ketamine enhances neuroplasticity, which is the brain cell’s ability to form new connections with one another. Not only has ketamine demonstrated the ability to repair neurons that were atrophied from chronic depression, but it also promotes the growth of new neuronal connections. Ketamine is also a “psychoplastogen” which refers to neuro-therapeutics that induce swift changes in plasticity following a single administration. These changes are thought to promote lasting changes in behavior patterns.
Quieting the Critical Voice: Ketamine also quiets the frontal cortex, which is the part of the brain that can keep us stuck in thoughts and behaviors that are defensive and self-critical. Similar to the nay-sayer disrupting a brainstorming session, this part of the brain often habitually and quickly shoots down new ideas that arise. In brainstorming, we say “there’s no such thing as a bad idea”, because dismissing every new thought that arises quickly kills any creative problem solving. With the frontal cortex more relaxed, we can relate to our challenges with fresh, creative eyes.
Hypnotherapy on steroids?: As a hypnotherapist, I’ve been leveraging unordinary states of consciousness to help clients for over 30 years. While hypnotherapy continues to be my first approach for many issues, including depression and anxiety, the process can be less dynamic because as I ask questions during hypnosis, the patient is lured toward the conscious mind to seek the answer. This makes trance more difficult to sustain. I’ve found that ketamine induces a trance-like state that is very similar to what my patients experience during hypnotherapy. The benefit is that we can rely on the ketamine to maintain the trance, allowing us to experience a much more dynamic, interactive session.
Legality: Currently, ketamine is the only medicine with the above benefits that is legal. Other promising neurogenetic medicines such as Psilocybin and MDMA have been given fast-track status by the FDA as breakthrough treatments (look for MDMA to be FDA approved in late 2023 and psilocybin in 2024-25), but currently, they remain illegal nationally, and in most states.
Which Mental Health Conditions Can Benefit from Ketamine?
Depression
PTSD
Anxiety
OCD
Substance abuse co-occurring with a primary psychiatric disorder
Relationship and existential issues such as existential distress
Bipolar I and II depressive phases (not mania)
Psychological reactions to physical illness and life-threatening illnesses
Suicidality (Cohesive SOULutions™ may refer imminently suicidal clients for IV ketamine in conjunction with therapy)
Chronic pain (sometimes requires higher doses of ketamine in a medically supervised setting)
Ketamine Administration
Ketamine has historically been given in medical settings. Many clinics offer ketamine to clients left alone in a treatment room. This can be traumatic for clients, and many prefer being supported while in an altered state of consciousness. Cohesive SOULutions™ is a ketamine-assisted therapy practice that provides support to clients in a comfortable setting while in an altered state of consciousness, but practices like ours can be hard to find.
Sublingual Ketamine and the Cohesive SOULutions™ Approach
Cohesive SOULutions™ recommends a sublingual formulation of ketamine with an onset in less than 5 mins. Following an evaluation, your prescriber will provide you with client-specific dosing based on your weight and body mass index (BMI). Sublingual ketamine is safe, and reliably promotes communication between you and our therapist, Paul, while you’re in a trance-like state. Psycholytic ketamine also allows people to tap into difficult states of mind with decreased fear. Further, it affords clients the ability to integrate healing after the acute phase of medicine starts to wear off. Based on 30 years of experience as a Board-Certified Clinical Hypnotherapist, Paul believes that the trance-like state is an ideal state of mind for psychotherapy. We find that most often the peak experience on the medicine lasts approximately 40-60 mins.
What Should You Expect to Experience in the Ketamine Session?
Many people in a trance-like state from sublingual ketamine report positive feelings. This has been described as euphoria, empathy, forgiveness, calmness, total relaxation and reduced “mind chatter”. Each ketamine session is completely different from the one prior, and also differs significantly from client to client. There is no way to predict what each session will be like for you. Experiences with ketamine can often lead to any one of the following:
Feelings of gratefulness, calmness, and acceptance
Feeling of flying
Feeling of falling
Willingness to approach topics and memories previously considered too scary to consider
Feeling of being reborn
Re-experiencing past events, including traumas with a new perspective
What is the Role of Psychotherapy in KAP?
Ketamine has been routinely given in sterile clinical settings for various mental health indications. In that setting, oftentimes there is no therapy provided and patients are left trying to make sense of the challenging experience on their own. The lack of therapy short-changes people seeking ketamine treatment as they are less likely to be able to integrate the experience into their everyday life. In 2015, Stephen Hyde published a paper titled, “Ketamine for Depression”, demonstrating ketamine’s ability to be used successfully via routes other than IV, thereby promoting easier use outside of a medical setting. Incorporating psychotherapy into ketamine treatment sessions was first described by Wolfson and Hartelius in 2016. By the mid-2000s many clinicians were using ketamine in conjunction with therapy. It has become increasingly more apparent that prescribers are not required during a psycholytic ketamine session, but a mental health professional with additional training in Ketamine Assisted Psychotherapy should be there to guide and hold space for clients on ketamine.
What is the Therapist’s Role?
Paul’s role is to be a source of support, comfort, and security. He will guide you through your journey with an empathic presence and will not be as talkative as he is in traditional therapy. It’s your journey and your time. Paul will encourage you to notice what is happening in your body, and to get in touch with your inner healing intelligence, encouraging you to allow the music to guide you. Paul will remind you that you are safe and will never leave you alone while you are on the medicine. When you face a challenging experience, Paul is trained and experienced to help you go toward it and be curious instead of running away… because sometimes, the only way out is through. This is the time to explore your unconscious. You are safe. Paul may encourage you at times to find your breath. If you don’t like a particular song, Paul may encourage you to explore what’s bothering you about the song and see if you can stay with it. He will remind you that all parts of you are welcome in the process and you should feel free to get in touch with any of your parts that come up. There are no “bad parts”. Your challenging experiences are welcome. We believe that with appropriate therapeutic support these experiences often lead to a deepening of the healing experience and can foster successful integration. Difficult experiences can occur, and these are areas for potential growth and deep insight.
Set and Setting
The outcome of a KAP session can be largely influenced by “set and setting”. Set refers to the client's mindset and setting refers to the supportive environment provided by Cohesive SOULutions™. Music is an integral part of the setting and can make or break a journey for some clients. Carefully curated playlists are provided by Cohesive SOULutions™ and are strongly encouraged. We do not recommend using music that is familiar to you. We are trying to foster new connections. The music on our playlists is selected to support the KAP process.
Some Goals of KAP Sessions
The goal in the psycholytic session is for clients to experience altered states of consciousness while at the same time being in the present with the here and now. When clients are in a trance-like state they can more readily access unconscious thoughts and feelings at a conscious level. The psycholytic experience affords the client and therapist the ability to work with material that could otherwise be challenging to access. Experienced therapists trained in KAP can engage the client while in a trance-like state and offer questions to deepen the client’s experience. Like SCUBA diving, once we dive in, we search around and explore while avoiding the tendency to make sense of the experience while in it. When we resurface, we have a trove to unpack. We unpack this a little immediately following the session and again during integration sessions.
Other goals may include:
Connection with Self, your Inner Healer, your Inner Knowing, or Inner Intelligence.
Connection with the universe.
Connection with the deeper meaning of life and life's purpose.
Creatively see things through a different lens, from a different perspective.
Inner Healing Intelligence
It is essential for clients to trust and connect with their inner healing intelligence, which is a person’s innate capacity to heal wounds from traumatic experiences. It’s important to be aware that each person has the potential to heal via contact with their inner healing intelligence. The ketamine and Paul are likely to facilitate access to a deep healing process, but they are not the source of this healing process, you are. The body knows how to heal itself but oftentimes needs help.
How Long Will the Benefits of Ketamine Last?
The duration of benefits is variable and depends largely on why the client sought out KAP to begin with. Typically, we will start clients with 6 sessions of KAP. Some clients express a desire to return for further courses of treatment, especially those with long standing depression who have previously been unsuccessful with multiple medications.
What are the Contraindications for Ketamine?
There are medical and psychiatric conditions that render people unable to receive ketamine therapy. These include:
Medical Contraindications
Untreated hyperthyroidism (overactive thyroid)
Untreated hypertension (high blood pressure)
Epilepsy (seizure disorder)
Aneurysm or dissection (serious problems with the blood vessels)
Heart disease, including heart failure, heart attacks or arrythmias
Severe breathing problems
Kidney disease
Advanced liver disease
Interstitial cystitis (bladder wall inflammation)
Glaucoma (elevated pressure inside the eye)
Active illicit substance abuse
Pregnancy
Psychiatric Contraindications
Schizophrenia
Psychotic features
Mania
Treating Suicidality with Ketamine
For expediency, any client of Cohesive SOULutions™ who identifies as having current, active suicidal ideation will be referred to a setting in which high-dose IV ketamine can be provided. Cohesive SOULutions™ will then provide Integration Therapy sessions between those ketamine infusions. As with any therapy process, if a client develops suicidal thoughts while undergoing treatment with us, they should immediately discuss this with Paul so appropriate action can take place.
What Substances and Medicines Should be Avoided in Clients Participating in Ketamine Assisted Psychotherapy?
While ketamine is known for not interacting with most other medications (including SSRIs), there are medications that should be avoided when receiving Ketamine Assisted Psychotherapy. Your medications will be evaluated and discussed by your prescriber. However, for reference, below is a list of some common medicines that can interact with ketamine or affect its outcome:
Theophylline or Aminophylline - can lower seizure threshold
Benzodiazepines, opioid analgesics, or other Central Nervous System depressants – can combine with ketamine to cause a dangerous level of sedation
Lamotrigine (trade name Lamictal) – can block some of the effects of ketamine.
Sleeping aids and sedatives such as Ambien, Benadryl, Remeron
We also recommend clients refrain from using the following substances during treatment as they can interfere with the benefits of ketamine, and some can lead to dangerous interactions:
Alcohol and cannabis
All Illegal substances such as cocaine, methamphetamine, etc.
Clients of Cohesive SOULutions™ should especially not use the above substances during ketamine treatment weeks.
Ketamine Doesn’t Help Everyone
A small percentage of clients will not respond to ketamine, even at higher doses. Additionally, some clients with rigid personality structures, including those with severe OCD or personality disorders and possibly those with profound PTSD, won’t be able to go into a trance-like state on the medicine and may find it challenging to maintain the benefits of the treatment experience. We don’t yet know enough about who won’t benefit from ketamine, so we recommend considering this treatment if no contraindications exist as the medicine is incredibly safe and well-tolerated. There is data to support that the elderly may respond less well to ketamine treatment.
The Cohesive SOULutions™ Process
Scheduling Your First Ketamine Assisted Psychotherapy Appointment:
Once it’s determined that KAP is a good fit for you, Paul will refer you to prescribers who are authorized to prescribe sublingual ketamine. You’ll need to connect with the prescriber for a medical evaluation, and if appropriate, they will prescribe ketamine for use in therapy sessions. Because of the time commitment required for each KAP session (at least two hours) Cohesive SOULutions™ does not schedule the initial KAP session until you have the medication in-hand. This avoids multiple cancellations that can result when trying to anticipate how long it will take for the medical evaluation and prescription process to complete.
Managing Expectations
Although it is rare, as with any therapy, clients can get worse before they feel better. Infrequently, a client can become worse after treatment including new or worsening suicidality. If this occurs, we recommend you discuss these feelings with Paul and activate a safety plan. Each medicine session will be different and there is no way to predict what will come up for you. We recommend clients come in with an open heart and open mind.
What to Wear to a Ketamine Session
Clients should wear loose fitting comfortable clothing. Scarves should be removed. Smart watches should also be removed, and phones silenced. We want you to have an experience without concern for possible interruption.
Eating and Drinking Before Sessions
This is controversial in the ketamine treatment space. We prefer to err on the side of caution and recommend avoiding eating and drinking 3-4 hours prior to taking the medicine. This will limit the amount of food in your stomach and minimize the likelihood of nausea.
Restroom Use Before Sessions
Clients should always use the restroom immediately prior to the medication session to avoid having to move around in an altered state of consciousness.
Blood Pressure Monitoring
Ketamine can impact blood pressure. If you have a tendency toward high blood pressure, we suggest that you take your blood pressure prior to each KAP session. This is a responsibility of the client and not the therapist. If blood pressure is a concern, clients can take their own blood pressure with a blood pressure cuff they purchase on their own, or one provided by Cohesive SOULutions™. We recommend digital upper arm cuffs and not wrist cuffs due to a concern regarding accuracy. Blood pressure cuffs can be found at pharmacies and online on Amazon. They range in price however many are in the $20-$40 range. Prior to the KAP session if your blood pressure is 150/90 or above Paul can help you relax, meditate, and find your breath. After 5-15 mins of relaxing the blood pressure can be repeated. Besides breathing and meditating other ways to quiet the mind include listening to calming music, smelling essential oils, guided deep breathing exercises, or a short hypnotherapy intervention.
Eye Mask
Cohesive SOULutions™ will provide a comfortable, blackout eye mask for KAP sessions. The mask will be labeled with your name and kept at the office for subsequent sessions. The purpose of the eye mask is to promote an internal experience. Ideally the eye mask is worn for the entire time the medicine is working, approximately 40-60 mins. You will know when the medicine is wearing off. Let Paul know when you feel that, and he will begin a 5 to 10 minute short hypnotherapy intervention to reinforce and help integrate the insights from the session at an unconscious level.
Safe Ride Home
Clients must have a safe ride home following ketamine sessions and they should not drive for the remainder of the day. It is not the responsibility of the therapist to confirm the client has a ride home.
After the Session
Clients remain in an emotionally healing and insightful place for up to 72 hours following a KAP session. This state is also emotionally vulnerable. It is highly recommended that clients plan for time after their sessions to nurture and heal themselves. This includes avoiding people and situations that create conflict, criticism and the like. Diligently reflecting and journalling during this window will provide huge benefit to the progress of therapy. Other benefits can come from creating art, singing, dancing, playing an instrument, authoring poetry, etc.
Client and Therapist Commitments for KAP Treatment
The client will agree to the following:
The client will remain free from illicit drugs and alcohol during the course of ketamine treatment.
The client will call 911 and activate their individual safety plan with any plans to hurt themselves or others before or after the session, should these thoughts surface.
The client will not take any dose of ketamine outside of the office and under the direct supervision of the therapist.
The client will not take the medicine if their blood pressure is 150/90 or above.
The client will avoid food and drink for 3-4 hours prior to the medicine session.
The client will not hurt themselves or the therapist during the session.
The client will not leave the office unless it is safe to do so.
The client understands there will be no sexual touch whatsoever and there will only be appropriate touch with the permission of the client.
The client will not drive home following the treatment session or later that same day.
The client will come to all integration appointments with their therapist to the best of their ability.
The therapist will agree to the following:
Paul confirms there will be no sexual touch and agrees to discuss this with the client at the beginning of each ketamine session.
Paul confirms that any supportive touch (i.e., hand holding, hand on shoulder) done during the session has been discussed thoroughly prior to the session and Paul will never touch the client during a medicine session without the permission of the client and never inappropriately
Paul agrees to never leave a client alone while on ketamine.
Preparation for first KAP Visit
Prior to the medicine session it is important to discuss with Paul the upcoming treatment session. During this visit Paul may ask:
What was your past experience with psychedelics, if any?
Have you taken ketamine before and if so, what was your experience?
What is important for Paul to know about what you would like to work on in these ketamine sessions?
Reminder: If you have any questions about the medicine itself you can always reach out to the prescriber or the pharmacy.
What Should You Expect During Treatment?
The effects of the medication typically appear a few minutes after you put the tablet into your mouth. Peak effects can last up to 60 minutes. Clients will typically lay still in a moderately dissociated trance-like) state. While less common, some of our clients laugh, cry, mumble, moan, make loud noises, or move their bodies in unusual ways sometimes that may look like punching and kicking. Some people experience fatigue, nausea, dizziness, lightheadedness, or drowsiness. Side effects, such as sedation or feeling “out of it”, can extend another 60-90 minutes after peak effects wear off.
Therapeutic Touch in Altered States of Consciousness
Supportive touch can be very beneficial to clients when in an altered state, however it is critical that you understand the rules around appropriate touch prior to any medicine sessions. Know up front that there will be NO sexual touch whatsoever. Clients should not be touched unless they ask the therapist specifically in that immediate moment and only if they consented to touch before the medicine was taken. We also recommend appropriate touch only, a hand on the shoulder, hand holding, a head on the head.
When is the Journey Over?
The journey is over after an hour or so when you begin to feel yourself emerging from the trance. If you let Paul know when you feel that he will ask permission to talk for a few minutes, and will engage in a hypnotic wrap-up of the session using suggestions and metaphors to reinforce the healing that occurred. Paul will then invite you to remove your eye mask when you are ready. Some people are ready to get up and ambulate and some want to lie down a little longer, even with the mask on. Rarely, ketamine can stick around longer than expected. This will be noted by Paul and appropriate time will be allotted for the next session.
Major Life Changes
Following KAP sessions, you may feel very compelled to make a life altering decision. We recommend clients sit with these feelings and not make any “big decisions” for at least 30 days from the medicine experience and after extensive discussions with Paul.
What Should Clients Do Following a KAP Session?
After the session clients are encouraged to go home, spend time listening to gentle music and journal about the experience. Clients are encouraged to either be alone or be with people who love and support them. We recommend immersion in nature following every session and there are several walking trails and nature preserves in the neighborhood around Cohesive SOULutions™. Many clients report feeling better shortly after the session. Some clients may have experiences during a medicine journey that leave them confused and those experiences can be difficult to describe. Don’t feel pressured to make sense of the journey immediately. Things will soon come together especially during integration sessions. Integration sessions can follow the medicine session immediately or days later. We suggest integration sessions be scheduled either immediately after the medicine session or within 72 hours when possible.
Summary of Evidence that Supports the Use ofKetamine for Mental Health Conditions?
There are many studies supporting the use of ketamine for mental health conditions. See the following articles for more detailed information:
Huang YJ et al. New Treatment Strategies of Depression: Based on Mechanisms Related to Neuroplasticity. Neural Plast. 2017; 2017:4605971.
Hamilton et al. Depressive Rumination, the Default-Mode Network, and the Dark Matter of Clinical Neuroscience. Biological Psychiatry. 2015 Aug 15;78(4):224-30.
Andrade, C. Ketamine for Depression, 1: Clinical Summary of Issues Related to Efficacy, Adverse Effects, and Mechanism of Action. J Clinical Psychiatry 2017 Apr;78(4):e415-e419.
Gaynes BN et al. What Did STAR*D Teach Us? Results From a Large-Scale, Practical, Clinical Trial for Patients With Depression. Published online 1 Nov 2009 https://doi.org/10.1176/ps.2009.60.11.1439.
Zarate CA, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression.Arch Gen Psychiatry. 2006 Aug;63(8):856-64.
Aan Het Rot M et al. Ketamine for depression: where do we go from here? Biol. Psychiatry. 2012 Oct 1;72(7):537-47.
DiazGranados N et al. Rapid resolution of suicidal ideation after a single infusion of an N-methyl-D-aspartate antagonist in patients with treatment-resistant major depressive disorder. J. Clin. Psychiatry. 2010 Dec;71(12):1605-11.
https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2014/ketamine.shtml
JenniferDore et al. Ketamine Assisted Psychotherapy (KAP): Patient Demographics, Clinical Data and Outcomes in Three Large Practices Administering Ketamine with Psychotherapy, Journal of Psychoactive Drugs, 51:2, 189-198, DOI: 10.1080/02791072.2019.1587556.