KETAMINE-ASSISTED
PSYCHOTHERAPY
(Currently wait-listing for KAP)

The most progressive type of treatment available for depression, PTSD, or other issues

                                                                                                                                                                                                 

• Do you struggle with unrelenting depression that has failed to respond to multiple forms of medication or other treatment?                                                                                               

• Have you failed to make or sustain progress for another type of mental health disorder? ​

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• Are you motivated to maximize your psychological and emotional growth in a safe, legal, controlled, and supportive setting?

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​Ketamine is an FDA-approved substance that's historically been used as an operative anesthetic, but has also been demonstrated as safe across a wide range of applications. The Center for HBH offers KAP for ketamine treatment at Wellward Medical, where an MD or psychiatric nurse practitioner will provide medical evaluation following psychological assessment and approval. Administration will be via IV infusion or intramuscular injection, with vital sign monitoring. 

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How does ketamine work for depression? 

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The exact reason ketamine can reduce depression and other symptoms hasn't been proven, as multiple effects to the brain have been identified as factors. The bulk of research for treatment-resistant depression (TRD) emphasizes effects to the receptor for a neurotransmitter called glutamate. Glutamate not only has downstream effects on other neurotransmitters affecting mood like serotonin and dopamine, but also plays a role in synaptic neuroplasticity. In recent years, ketamine research has included effects to a neurotransmitter modulator called brain-derived neurotrophic factor (BDNF), which is also linked to neuroplasticity. However, a factor less researched and discussed is the impact of ketamine's dissociative effect on the brain, described below. Historically, the medical treatment approach to TRD has viewed the dissociation as a side effect to block or lower, and sometimes IV infusions include another drug to minimize it.

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Is ketamine a psychedelic? 

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Although there are certainly differences between ketamine and the ''classic'' psychedelics such as psilocybin and LSD, ketamine's dissociative effect has a key similarity for mental health. Ketamine and psychedelics temporarily disconnect activity between midbrain structures collectively known as the Default Mode Network (DMN)--areas that revert to habitual rumination and reflection when we aren't otherwise focused or distracted. As the seat of our repetitive neural networks, or thought patterns, the DMN can also be understood as the source of our identity, or ego.

 

The DMN's reasoning capacity and ego boundaries are obviously necessary and useful: along with the rest of the prefrontal cortex, it's the product of human evolution beyond the instinctual animal brain, or limbic system. It enables us to create personal narratives--stories about ourselves and the world--that help us cope and create meaning. Sometimes these are positive, but often they're distorted and a factor in depression and anxiety. By temporarily disconnecting the Default Mode Network, ketamine and psychedelics can push aside these stories that shape our identity, a process sometimes referred to as ''ego disruption.'' This is helpful for loosening up negative stories that talk therapy (cognitive therapy) can't budge, but it's important to understand what else can happen as a result. The evolutionary tradeoff for the meaning-making mind has been separation from animal instincts that discharge physical tension, which is created by threat or stress. Psychedelic researcher David Nutt has stated that in the DMN, ''we've found the neural correlate for repression.'' When the cognitive patterns anchoring our perspective get released, so can what's beneath. Read more about this below.

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What are the risks of ketamine therapy? 

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Ketamine affects the urogenital tract, and the benefits may not out weigh the risks for those with intersitial cystitis or similar conditions. Otherwise, there are very few known physical risks, and medical assessment screens and controls for those. However, since ketamine behaves like a psychedelic, the psychological risks are essentially the same. The latest neuroscientific model for a unified psychedelic theory involving the Default Mode Network, or ''internal mind'' was published by leading researcher Robin Carhart-Harris and colleagues. Based upon brain imaging studies, the REBUS model (RElaxed Beliefs Under pSychedelics and the Anarchic Brain) proposes that these substances temporarily disorganize normal connections across the brain, creating the ''hallucinogenic'' experience and interrupting the normal patterns in the DMN. When this occurs, what's repressed in the limbic system--which connects feelings, memories, and physiological reactions--can then surface, an effect they describe as''liberation of bottom-up signaling.'' While this sounds purely positive, in reality it can create emotional vulnerability and nervous system overwhelm. For example, as depression lifts, panic emerges. As anxiety improves, buried feelings of anger or sadness may set in.

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Trauma therapists are already familiar with this phenomenon, as ''bottom-up'' approaches such as EMDR or somatic therapy use techniques that distract or bypass the DMN.  Similar to psychedelics (but without the trip!), upper-level thought processes are pushed aside to fully access and reprocess charged memories. When change occurs at this level, shifts in related thought patterns tend to occur without effort. However, trauma therapists know that, depending upon the severity of a client's trauma history, bypassing the DMN must be approached with caution to avoid unearthing more than can be tolerated. Ketamine and psychedelics amplify the effect of bottom-up therapies from a screwdriver to a power drill, creating even greater risk in most cases. However, when ketamine treatment is done with the harm reduction concepts, psychological preparation, and integration essential to responsible psychedelic therapy, the potential for risk is translated into power for healing. It exceeds what even the best non-drug assisted therapies can do.

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How is Ketamine-Assisted Psychotherapy different from regular ketamine treatment?

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Given the risk described above, you may be wondering: If this is true, how do so many people have only positive outcomes from medical ketamine treatment? 

 

It's widely recognized within the psychedelic-assisted therapy field that ketamine shares the unmeasurable, but no less important phenomenon of response to ''set and setting:'' a difference in outcome depending on the environment (setting) and user intention (mindset). As the historic psychologist and psychedelic advocate Timothy Leary was quoted: ''The drug dose does not produce the transcendent experience. It merely acts as chemical key--it opens the mind, frees the nervous system of its ordinary patterns and structures. The nature of the experience depends almost entirely on set and setting.’’ 

 

In the case of ketamine, the standard medical approach doesn't promote it as a psychedelic, so the patient typically doesn't think of it as such. Disrupting the DMN, or ego, enough to bring about nervous system change isn't the goal, so outcomes typically stay in the range of a mood boost and a decrease in the most intense symptom or thought process, such as suicidal ideation. The therapeutic term commonly being used for the phenomenon that somehow regulates this is ''inner healing intelligence.'' Just as the body knows how to fully heal a broken bone once it is set properly, the mind-body (mind and nervous system) knows how to heal itself optimally when the treatment conditions are right. Otherwise, a spectrum of unpredictable outcomes can occur depending on a combination of factors in treatment setting and interior mindset. These typically range from 1) positive, but temporary and superficial effects, 2) a negative or destabilizing experience, or 3)''non-response'' (failure to break through a rigid, highly control-oriented Default Mode Network). Another possibility is ''spiritual bypassing''--a mystical experience with little to no psychological growth.

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What is Ketamine-Assisted Psychotherapy?

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The term ''Ketamine-Assisted Psychotherapy (KAP)'' is a term currently applied to various approaches.  It may refer to one that recognizes inner healing intelligence, but still holds the treatment intention (an element of ''setting'') to work within the Default Mode Network and optimize neuroplasticity for thought pattern change. It may or may not include guided therapy during the ketamine treatment itself, which is known as a psycholytic approach. This more cognitive approach may be safer for those with severe complex trauma and and/or high-risk symptom history.

 

In many cases, KAP refers to an integration-only approach, meaning that the therapist helps you sort out the disruptive effects (whether intense or confusingly mild and vague) of the drug after the fact. Historically, this has been a need when illegal psychedelic use can't be therapeutically condoned up front. Since ketamine is legal, it's arguably insufficient for the best outcome.

 

As a somatic, or ''bottom-up'' therapist, I use KAP to harness the psychedelic potential for fuller DMN/ego disruption, and resulting limbic system release and reprocessing. (Note that this is not a reference to ''ego death,'' which is an important concept to psychedelic use, but not essential for treatment progress.) To make sure that this happens at a safe and comfortable pace for you, I emphasize preparation as much as integration. 

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I use Internal Family Systems (IFS) as a psychological framework for the process. IFS is a widely used approach for KAP and other psychedelic-assisted therapies, as it provides a metaphorical map for the Default Mode Network and emotions held in the limbic system. To make that map as real for you as possible and create a ''soft entry'' into ego disruption prior to ketamine treatment, I use a combination of EMDR, mindfulness-based somatic approaches, and Jungian ''active imagination'' (guided imagery) work. C.G. Jung was a key historical psychiatrist who developed concepts essential to the psycho-spiritual nature of psychedelic therapy: He used the term '''Self'' for inner healing intelligence, and portrayed the work of overcoming ego dominance as a hero's journey into greater acceptance and purpose. By engaging the non-linear side of the brain, active imagination allows psychological expansion (and integration) that seems to mimic aspects of the psychedelic effect.

 

To summarize the benefits of this KAP approach:

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• It avoids the risk of a challenging ketamine session, non-response, or a spiritual bypassing effect.​​

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• Instead of letting ketamine (or an illegal psychedelic) act as an initial disruptor and waiting to see what needs to be integrated, it gets DMN/ego disruption work started first. Ketamine then amplifies that progress. It allows for the deepest and fastest pace of progress your nervous system can tolerate, which is the most cost effective and efficient way to improve your mental health.

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• The specificity of intention created by preparation therapy allows for a more measurable and enduring outcome. Instead of just experiencing mood improvement, you will understand the obscured roots of your issues and maximize the window of neuroplasticity with related shifts in thinking. You will still experience your issues and triggers, but at less intense octaves and with a greater sense of empowerment due to clarity about the patterns. 

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• Booster treatments, which are often needed at some point after standard ketamine treatment, will be less likely, and if necessary, they will be opportunities for increasingly deeper levels of work. 

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Is ketamine recommended for any mental health disorder?

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Ketamine treatment can be useful for most mental health disorders, but it is not recommended if you have schizophrenia or another primary psychotic disorder. It is also not recommended for unstabilized bipolar disorder. However, note that people with developmental trauma history (C-PTSD) are often misdiagnosed with bipolar disorder due to vacillation from depression to anxiety or anger rather than depression to mania, which has very specific features. 

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If suicidal ideation or a passive death wish is a newer symptom in your life or one that you are unlikely to act upon, ketamine may bring significant relief from that in as little as one session. However, for someone who has struggled with a pattern of suicide attempts or threats, ketamine may only create more vulnerability. Because of the psychedelic effect on the brain and nervous system described above, it's important to consider that suicidal ideation, as frightening as it may be, is a coping mechanism suppressing more painful feelings. A thorough psychological assessment is important. 

 

If you've been diagnosed with borderline personality disorder, or struggle with symptoms such as repeated suicide attempts or threats, self-injurious or reckless behavior, extreme instability of relationships or intense fear of abandonment, this form of KAP is likely to feel too disruptive, and is not recommended. If you identify with these symptoms currently, Dialectical Behavioral Therapy is the recommended initial treatment approach. After stabilization with DBT, a cognitive approach to KAP could then be considered.

 

If you have an active substance use disorder, it's important to seek formal comprehensive treatment and develop a recovery lifestyle first, as ketamine is not a magic bullet. Although ketamine's neurotransmitter benefits can be useful for mood or cravings in recovery, and ketamine-assisted psychotherapy can help you address trauma or emotional wounds masked or created by addiction, many psychological patterns are rewired best by new behaviors, routines, and positive connections with others.  Ketamine does facilitate ego maturation that chronic substance abuse arrests, but it's unlikely to substitute the lifestyle efforts that build maturity naturally. 

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For obsessive-compulsive disorders, which imply extra rigidity to repetitive neural networks in the Default Mode Network, ketamine may not alleviate OCD symptoms as quickly as other types. More treatment than average may be necessary to make headway. Ketamine and other psychedelics are likely the best treatment available for the issue, but extended preparation therapy targeting the underlying root issue seems to be extra important in this case. For example, non-response would be highly likely without thorough preparation.

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Not all providers would agree with my above views about diagnosis, but it's a practice-informed perspective that errs on the side of caution for your well-being. 

 

Ketamine treatment may seem overwhelming or intimidating, but you'll receive support from start to finish, with assistance from the Wellward Medical Patient Navigator to discuss cost, establishment of a safe relationship in therapy sessions prior to actual ketamine treatment, and a physician's oversight of all the medical aspects. 

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As the therapist in the process, it's always amazing to help clients with this deep work. I would be honored to hear your story and facilitate your change.

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