Ketamine Assisted Pschotherapy

What is Ketamine?

Ketamine is a Schedule III medication that has long been used safely as an anesthetic and analgesic agent. Ketamine is now increasingly clinically used “off-label”, at sub-anesthetic doses for various chronic “treatment- resistant” mental conditions such as depression, OCD and PTSD.
Ketamine is classified as a dissociative anesthetic, dissociation meaning a sense of disconnection from one’s ordinary reality and usual self. At the dosage level administered to you, you will most likely experience mild anesthetic, anti-anxiety, antidepressant and potentially, psychedelic effects for anywhere from 15-120 minutes. Relaxation from ordinary concerns and usual mind, while maintaining conscious awareness of the flow of mind under the influence of ketamine is characteristic. This tends to lead to a disruption of negative feelings and obsessional reoccupations. 

How does Ketamine work?

The current, most probable, understanding of ketamine’s mode of action is as an NMDA antagonist, working through the glutamate neurotransmitter system. This is a very different pathway than that of other psychiatric drugs such as the SSRIs, SNRIs, lamotrigine, anti-psychotics, benzodiazepines, etc. However, there is no consensus on the exact mode of action. Other mechanisms may well be found central to ketamine’s effects.In science and medicine, structure and function are intimately related. Knowing the chemical structure and functional effects of drugs is useful for distinguishing them based on the effects they have and how they will be metabolized within the body. 

To classify psychoactive drugs more specifically, you need to know two things:

1. What is the specific character of its primary subjective effects?

2. What is the molecular mechanism that those effects depend on? With that in mind, let’s look more closely at what distinguishes three classes of psychoactive drugs: dissociatives, hallucinogens, and empathogens.

You may know them by their popular exemplars:

1. Dissociatives, a class that includes ketamine and nitrous oxide

   2.     Empathogens, which includes MDMA (ecstasy)

   3.     Hallucinogens, which includes LSD, psilocybin, ibogaine, and mescaline Dissociation is a strange and fascinating psychological state. You are generally aware of your surroundings, yet feel disconnected from your body and identity. 

   Eligibility for Ketamine Treatment

   Ketamine was approved by the FDA for use as an anesthetic agent several decades ago. Ketamine has an extensive record of safety and has been used at much higher doses for surgical anesthesia, without respiratory depression. The International Journal of Transpersonal Studies 187 administration of ketamine in lower, sub-anesthetic doses to treat pain, depression, or other psychiatric diagnoses is a newer, off-label use of ketamine. Psychiatric use of ketamine has become relatively widespread in recent years, has been studied and promoted by researchers at the National Institute of Mental Health, and has had publicity as the newest anti-depressant with its own novel pharmacological mechanism of action. Ketamine has been administered by intravenous, intramuscular (IM), and intranasal routes. Often, it has been used after other treatment approaches have been unsuccessful. Once you indicate that you have understood the benefits and risks of this treatment, you will be asked to sign this form in order to participate in this treatment. You will be given a signed copy of this form to keep for your own records. This process is known as giving informed consent. By signing this document, you indicate that you understand the information provided and that you give your consent to the medical procedure to be performed during your participation in ketamine treatment.Before participating in ketamine treatment, you will be carefully interviewed to determine if you are eligible for ketamine use for your mood disorder. This will include a medical/psychiatric history, review of your previous medical/psychiatric records if necessary, and administration of brief psychological tests to assess your state of mind.

   Medical exclusions may include: uncontrolled hypertension, congestive heart failure, other impaired cardiac status, COPD, severe obesity, kidney/bladder disease, liver disease, prior adverse response to anesthesia, allergy to ketamine, pregnancy, untreated hyperthyroidism, or closed angle glaucoma. Psychiatric exclusions include: any mania, schizophrenia, schizoaffective disorder, significant dissociative disorder, alcohol/substance abuse or severe personality disorders.

   Overview of Ketamine (IM) Assisted Therapy—KAP  

   During the Ketamine administration session, you will be asked to make two (2) agreements with your therapist to ensure your safety and well-being:

   1.     You agree to follow any direct instructions given to you by the therapist(s) until it is determined that the session is over, and

   2.     You agree to remain at the location of the session until the therapist(s) decides you are ready to leave.

    

   The length of ketamine sessions varies from person-to-person and from experience to-experience. You will be mostly internally focused for the first 45 minutes to one-hour and-a-half following intake of ketamine. You will continue to remain under ketamine’s influence at a lesser level for at least one hour. You will bring your agreed upon prescribed dose of ketamine with you.

    Preparation for a ketamine session requires assessment by your therapist of your readiness and a sense of connection between you and your therapist. We are engaging in a therapeutic endeavor to benefit you and those who are affected by you. Together, we are creating a therapeutic state that is based on rapport and trust (set) in a safe and conducive setting. That will require prior sessions to your use of the drug. After ketamine medicine session, you will have 2 follow-up sessions that focus on integration of your experience and may lead to further sessions, if you so wish, and if that is in accord with your therapist’s view of your treatment. You may ask the therapist(s) any questions you may have concerning the procedure or effects of ketamine at any time. Your consent to receive ketamine may be withdrawn by you, and you may discontinue your participation at any time up until the ketamine is taken by you.

    

   The Ketamine Experience

   The ketamine experience is characterized by the relaxation of ordinary concerns and usual mindset, all while maintaining conscious awareness. This tends to lead to a disruption of negative feelings and preoccupations. Some ketamine providers feel that this interruption--and the exploration of other possible states of consciousness--can lead to significant shifts in overall well-being.

   At lower doses, you will most likely experience mild anesthetic, anxiolytic, antidepressant, and psychoactive effects. You might experience increased sensitivity to light and sound, as well as an altered sense of time. Some people experience empathogenic (similar to MDMA) effects in this dose range. This state may also enhance participation in psychotherapy, as defenses are relaxed, yet communication with others is still possible.

   Higher doses are more likely to produce psychedelic, dissociative states that are largely internal journeys away from the external world. Body sensations are greatly diminished. Such journeys may provide a more robust treatment effect, often assisting in the resolution of existential concerns, accelerating psychological and (and possibly spiritual) growth, and promoting a positive change in outlook and character that we refer to as a ​transformative​ response.

   Sensory effects of ketamine may include distorted visualization of colors, feeling suspended in space or floating, experiencing out-of-body sensations, vivid dreaming, and changes in visual, tactile and auditory processing. Synesthesia (a mingling of the senses) may occur. Familiar music may not be recognizable. An ordinary sense of time may morph into time dilation.

   These effects typically start 5 to 10 minutes after ketamine dosing. The peak effects typically last 20 to 30 minutes, and then slowly diminish for the next hour.

   Some alterations in sensory perception, speech, and motor ability may continue for approximately 5 hours.

   Two to three hours after ketamine administration, clients can return home with another driver. Driving an automobile or engaging in hazardous activities should not be undertaken on the day of the administration, and not until all effects have stopped.

    

   Why Ketamine Assisted Psychotherapy (KAP)?

   Research shows the administration of ketamine is most effective when paired with psychotherapy. We offer a psychotherapy program that will prepare you for your ketamine sessions, encourage you to explore your mind while within the ketamine space, and assist you in integrating your experiences afterwards.

   This program emphasizes the potential for change, and such change is best facilitated within a structured, supportive psychotherapeutic environment with providers who are aware of your issues, hopes, desires, and struggles.

   Ketamine has the potential to create a non-ordinary state of consciousness, facilitating a profound transpersonal or mystical peak experience. These sorts of peak experiences have been shown to expand one’s sense of self and understanding of existence and may enable you to access your own healing wisdom. Your providers serve as guides and assist in processing the experience and its impact on your everyday life.

   Ketamine’s altered state can create conditions of relational and psychological openness​, and thus we believe that trust in your providers enables the deepest possible work to occur. Psychotherapy sessions are meant to build that sense of connection and trust between you and your providers.

   Many have found it beneficial to set an intention for the experience. Intentions should be personal and focused, which could include alterations in habits (such as the use of alcohol or cannabis, exercising, etc.), shifts in self-defeating patterns of thought or social interactions, or exploration of spiritual/existential realms. Our team will work with you to formulate your goals, ​and will also encourage you to hold those lightly, ​as resistance or attempts to control the experience can produce anxiety.

   Your experience will be unique to you, and each of your sessions will be different. All such journeys are adventures that cannot be programmed. They evolve from your own being in relation to this medicine, and it is best to relax into the path that unfolds. Many enjoy the journey, while others do not. Everyone comes through it, and often with greater insight into themselves and their lives. Our therapy program is designed to assist you in integrating these insights into your daily functioning.

   As a byproduct of your experience, you may feel improvement in your emotional state and reduction in symptoms such as depression, anxiety, and post-traumatic manifestations. You may notice that you are a bit different after a ketamine experience, and that difference may feel liberating, allowing for new perspectives and behavior.

   These shifts may happen during treatment, in the aftermath, and/or in the days and weeks that follow. Some experiences may be temporarily disturbing to you, and we will work to help you understand these in context of your healing process. Ultimately, we are working to assist you in changing patterns of mind, mood, and behavior that cause you difficulty and distress.

   Both psychotherapy and medication (including psychedelic medicines) are effective, but the combination has been shown to be much more powerful than on its own. Many come to us having attempted numerous treatments, and we want to ensure that you have the best possible outcome for your investment. This is a unique opportunity for growth and change, and so we encourage you to actively engage in the therapeutic process as well as the medication administration.

    

   Monitoring

   It is essential that you be followed very closely during and after your treatment. This will include blood pressure and pulse measurements, some psychological measurements before and after your session, close supervision, and support during your treatment session with your physician/psychiatrist/psychotherapist, and follow-up telephone and in-person contact with your treatment team. You will be entering a psychotherapy program that will prepare you for your ketamine session(s) and assist you in integrating your experience(s) afterwards. This program emphasizes the possibilities for change and the seriousness of your and our effort to assist you.
   

   How long will it take before I might see beneficial effects?
   You may experience important changes in personality, mood, and cognition during treatment, in the immediate aftermath, and in the days and weeks that follow. Some experiences may be temporarily disturbing to you. The ketamine experience itself is designed to enable your own healing wisdom to be accessed and beneficial to you. The psychotherapeutic support you will receive will aid you in making your experience(s) valuable and understandable to you. Some experiences may be temporarily disturbing, but the integration process may greatly help you move to clarity and understanding.

    

   Potential Risks of Ketamine Therapy

   Ketamine has an extensive record of safety and has been used at much higher doses for surgical anesthesia, without respiratory depression or other adverse reactions.
   You will be asked to lie still during the ketamine the medicine session because your sense of balance and coordination will be adversely affected until the drug has worn off, generally two to four hours after ingestion. Other possibilities for adverse effects include blurred and uncomfortable vision (you are advised to keep your eyes closed until the main effects have worn off), slurred speech, mental confusion, excitability, diminished ability to see things that are present, diminished ability to hear or to feel objects accurately including one’s own body, anxiety, nausea and vomiting. Visual, tactile, and auditory processing are affected by the drug. Music that may be familiar may not be recognizable. Synesthesia (mingling of the senses) may occur. Ordinary sense of time will morph into time dilation.

    

   Because of the risk of nausea and vomiting, please refrain from eating and drinking for at least 4 hours preceding the session. Eat lightly after. Hydrate well in that same time frame.

   Ketamine can cause a significant, but not dangerous, increase in blood pressure, but usually not pulse rate. If you think you are at risk for this, please let me and the prescriber know.
   The administration of Ketamine may also cause the following adverse reaction: tachycardia (rapid heart rate), diplopia (double vision), nystagmus (rapid eye movements), increased intraocular pressure (increased pressure in eye) and anorexia (loss of appetite).

    

   Potential for Abuse and Physical Dependence

   Ketamine is a controlled substance and is subject to Schedule III rules under the Controlled Substance Act of 1970. Medical evidence regarding the issue of drug abuse and dependence suggests that Ketamine’s abuse potential is equivalent to that of phencyclidine and other hallucinogenic substances.

   
   Phencyclidine and other hallucinogenic compounds do not meet criteria for chemical dependence, since they do not cause tolerance and withdrawal symptoms. However, “cravings” have been reported by individuals with a history of heavy use of “psychedelic” drugs. In addition, ketamine can have effects on mood (feelings), cognition (thinking), and perception (imagery) that may make some people want to use them repeatedly. Therefore, ketamine should never be used except under the direct supervision of a licensed medical provider.

   Repeated, high dose, chronic use of ketamine has caused urinary tract symptoms, even permanent bladder/kidney dysfunction in individuals abusing the drug. This does not typically occur within the framework of use for our purposes.

    

   Alternative Procedures and Possibilities

   No other procedure is available in medicine that produces ketamine’s effects. Major Depression (MDD) and Bipolar Disorders are usually treated with anti-depressant medications, tranquilizers, mood stabilizers, and psychotherapy. Electroconvulsive therapy (ECT), and the recently introduced Transcranial Magnetic Stimulation (TMS), are also in use for treatment-resistant-depression. Ketamine has also been used in the treatment of addictions and alcoholism as part of comprehensive and usually residential treatment programs, primarily abroad.

    

   Voluntary Nature of Participation

   Please be aware that the Food and Drug Administration (FDA) has not yet established the appropriateness of Ketamine Assisted Psychotherapy, and its use is considered off-label, the only official “indication” for use of ketamine being anesthesia. Your awareness of this situation is key to understanding any liability associated with your use of ketamine. Your informed consent indicates you are aware of this situation. Ketamine is a new psychiatric treatment—the primary studies have been with depression, bipolar disorders, and alcoholism. It is not yet a mainstream treatment, though there are now many studies that demonstrate that it may be an effective treatment. That effect generally International Journal of Transpersonal Studies 191 occurs with more than one treatment and is most robust when part of an overall treatment program. It may not permanently relieve depression. If your depressive symptoms respond to Ketamine Assisted Psychotherapy, you may still elect to be treated with medications and ongoing psychotherapy to try to reduce the possibility of relapse. Over time, you may also need additional ketamine treatments or other therapies to maintain your remission. Your decision to undertake Ketamine Assisted Psychotherapy is completely voluntary. Before you make your decision about participating in KAP, you may ask and will be encouraged to ask any questions you may have about the process.