KETAMINE-ASSISTED
PSYCHOTHERAPY
The most progressive type of treatment available for depression, PTSD, or other issues
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Have you found it impossible to face trauma history or seek help for PTSD?
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Do you struggle with unrelenting depression that has failed to respond to multiple forms of medication or other treatment?
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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?
What is ketamine? How is it safe?
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. Unlike opioid-based anesthetics, it does not suppress the respiratory system. Although it can be contraindicated for certain medical conditions such as uncontrolled hypertension, it poses virtually no overdose risk. Ketamine is now being used as a medication that alleviates depression and some types of chronic pain for extended periods with cumulative use, as well as a vehicle for an altered state of consciousness that facilitates psychotherapy for trauma and other mental health problems. The Center for HBH is thrilled to now offer preparation, guided ketamine therapy, and integration services at Wellward Medical.
Ketamine's ability to change consciousness occurs through its dissociative effect, meaning that it creates some degree of detachment from one's usual sense of self and/or the body. Like psychedelics, at high enough doses, this can range from a near-death experience to temporary but complete detachment from identity, also known as ego dissolution. While research shows that reaching this state often has enduring benefit to well-being afterward, it can be terrifying at the time. In contrast, Wellward Medical physicians are neither using very high doses that would create a very frightening experience, nor a sedated dosing approach (common to many ketamine treatment facilities) that treats depression pharmacologically, but suppresses dissociative experience and offers no psychotherapeutic benefit. Wellward typically begins with an IV infusion in order to control and identify an appropriate individualized dosage, then switches to intramuscular injections that are less of a hindrance than an IV (although continued infusions are an option). Both methods include vital sign monitoring.
How does ketamine work?
Although the exact reason that ketamine reduces depression has not been proven, antagonist action at the brain's NMDA receptors may lead to a resetting effect for neurotransmitters of well-being such as dopamine and serotonin. For example, it becomes easier for the brain to experience neurotransmitter balance with a lower degree of external rewarding stimuli, from drugs of abuse to sugar or screens. Although the predominant message about the efficacy of ketamine for depression is rooted in research on this neurochemical pathway, other research reflects that other NDMA antagonist medications have failed to demonstrate the same antidepressant effects. This suggests that the dissociative effect of ketamine may actually be the key reason it can improve mental health disorders.
Like psychedelics, ketamine is thought to impact mid-brain structures collectively known as the Default Mode Network (DMN)--parts that revert to rumination and reflection when the brain isn't otherwise focused or engaged. Although the DMN is not yet a universally accepted scientific idea, it was developed based upon brain imaging studies. As the seat of our repetitive neural networks, or thought patterns, the DMN can also be understood as the source of mental constructs such as our sense of ''self,''--or in psychological terms, the ego or identity. By extension, the DMN is of course also that which makes us feel separate from others.
Although development of the ego and its sense of ''I'' is necessary to create independence from primary caregivers, it also holds our entire history of emotional adversity and conflicted feelings. It then expresses that or tries to keep them in check through personality traits or symptoms. Many people over-identify with their ability to repress emotions, while others struggle not to over-identify with their emotions. Even in the latter case, surface emotions and coping mechanisms typically function to repress the key root issues. Either way, the DMN is a top-down organizing function for the brain to keep unconscious material held in the limbic system from constantly overwhelming us, with a side effect of compartmentalization that creates new problems. In Michael Pollan's book on psychedelics How to Change Your Mind (now a docuseries) he quotes psychopharmacologist and psychedelic researcher David Nutt as saying that in the DMN, ''we've found the neural correlate for repression.''
Pollan also notes that neuroscientist Robin Carhart-Harris suggests mental health disorders result from ''an excess of order...when the grooves of self-reflective thinking deepen and harden, the ego becomes overbearing.'' The dissociative effect of ketamine provides temporary disconnection from these ego grooves or ''ego parts'', which show up as dysfunctional coping mechanisms that are the symptoms of mental health disorders. In cases where symptoms have been active for many, many years, we tend to see them as ''personality traits.'' Read below to understand why ketamine-assisted psychotherapy, as opposed to isolated ketamine treatments, is more likely to translate this temporary disconnection into lasting change.
What does ketamine feel like?
Although ketamine is a synthetic substance developed in a lab, it can have an entheogenic effect like psychedelic plant-based medicines, creating feelings of profound spiritual connection. Even when people don't have a blissful or out-of-body experience, they tend to find it relaxing and enjoyable. People experienced with psychedelics do often report that it feels distinctly different from other altered states of consciousness, however. Although ketamine can create feelings of compassion for self and others like empathogens such as MDMA, psychiatrist and ketamine-assisted psychotherapist Phil Wolfson suggests that ketamine should be more accurately termed a ''euphoragen.'' Wolfson also notes how variable the ketamine experience can be, stating 'in general, the greater the dosage, the greater the [effect], but one person's point of [effect] is another person's point of neutrality or another human's profound experience.'' (Experiences guiding people in ketamine sessions at Wellward Medical support Wolfson's statement.)
As stated above, the dosing in this case is highly unlikely to cause a frightening level of disruption to the cohesive ego state or a ''bad trip.'' Even if the psychological content that arises has a dark theme, or you're trying to focus on trauma history, the nature of the dissociative effect (which inherently creates distance from the intensity of difficult feelings) combined with the safety of the setting generally keeps things very manageable. This is especially true if you've done preparation sessions and/or taken the time to set an intention. Those who skip preparation, especially the basic step of intention, seem to be at higher risk of an unpleasant or simply bland experience, which from a psychological point of view, may be a protective blocking feature by the ego parts. Read more about this below.
How is ketamine-assisted psychotherapy different from regular ketamine treatments?
Ketamine treatments administered with some degree of sedation (which may still be the case even if the patient remains conscious), are based upon the premise that the anti-depressant effect arises mainly from NMDA receptor antagonism and other mechanisms affecting neurotransmitters. As such, the dissociative nature of ketamine has historically been viewed as undesirable side effect of treatment. Yet, suppressing this blocks the altered state of consciousness that can both 1) create a profound sense of connection to something meaningful beyond the default ego state and 2) create a window of neuroplasticity during which therapeutic work can be significantly enhanced.
Although ketamine treatments without sedation still allow the dissociative effect and a corresponding window of neuroplasticity, the addition of a comprehensive psychotherapy approach creates a structured container for understanding and measuring the effect so that benefits are more enduring. Instead of just experiencing an improved mood, you gain insight into the obscured roots of your depression or other disorders, and become better at avoiding or managing triggers from that point on. Booster treatments, which are often needed at some point after standard ketamine treatment, will be less likely, and if necessary, they'll be opportunities for deeper levels of work. By quieting the neural networks in the midbrain that hold beliefs, self-perceptions, rumination patterns, or obsessions or compulsions, a series of non-sedated ketamine treatments seems to ''peel back'' symptoms in an incremental, layered approach, revealing feelings or capacities for awareness that have been suppressed. Combining treatments with a comprehensive psychotherapy approach such as Internal Family Systems (IFS)--which as a stand-alone therapy, already aims to identify and calm overbearing ego grooves/parts--enables you to maximize your results for at least three reasons.
1) Using IFS in preparation sessions creates knowledge of your ego grooves/parts in advance, enabling you to identify a highly strategic intention that can be adapted further as you gain new insight with each ketamine treatment. This makes it easier for you to measure the efficacy of the outcome--to notice and understand new connections--and to reframe your perspective and behavior accordingly for lasting change.
2) IFS allows ketamine therapy to progress at the optimal pace for trauma, with minimal risk of unsafe feelings, an emotional abreaction, or a blocked experience. Post-traumatic stress reactions, no matter how dysfunctional, should accurately be viewed as psychological adaptations to the traumatic wound itself. Particularly in the case of complex developmental trauma, these adaptations become protective coping mechanisms and even identities that can unearth more vulnerability when moved out of the way. If you engage in a ketamine series without the therapeutic perspective, you risk feeling worse at points without understanding why, or without therapeutic support to process and integrate the new level of vulnerability. Alternatively, sometimes the parts can seem to block the dissociative benefit of ketamine to prevent that vulnerability, resulting in what seems like a sub-par or ineffective outcome.
3) Establishing a connection with a therapist in advance, who will then be familiar with your ego parts and your intention, will enhance your sense of safety during the ketamine treatments. It may also create an opportunity for enhanced IFS work. Although sometimes people have a (typically blissful) highly internalized dissociative experience (without much to say out loud) .the period just after the effect begins to decline can be highly useful for deep therapeutic work related to the intention. Although ketamine experiences vary widely, new connections often aren't made during the dissociative state itself, as it may feel disjointed. Even if the period immediately afterward doesn't translate directly into IFS work, the time to process about your dissociative experience will be useful, as the therapist may begin noticing new connections before you do. Regardless of how the ketamine treatment session itself plays out, the dissociative effect has a remarkable catalyst effect that becomes apparent through integration therapy. My observation is that this is particularly true if if you've done preparation and intention work.
Will this be as effective as a plant-based medicine?
You may wonder how a synthetic treatment could be as effective for healing as a plant-based substances like psilocybin or ayahuascua, but what ketamine and psychedelics seem to have in common is the impact to the Default Mode Network. Also, experiences and observations suggest that the ''Self'' proposed within the Internal Family Systems therapeutic model--a compelling vital force that drives us toward wholeness-guides the effect through the vehicle of intention regardless of the substance type, with even greater impact through preparation and integration. Although in IFS the ''Self'' has important connotations to ''Self-parenting,'' (a healthy internal locus of control) it can also be conceptualized as your transcendent ''Higher Self,'' or your highest potential and purpose--that which is greater than the sum of your limited ego parts. Depending upon your belief orientation, it may be more useful to think of it as the ground of being beneath all ego layers--that which separates human consciousness from whatever is beyond it (such as the quantum field). Although the Self seems to always be there responding to intentions we set and actions we take, ketamine and the other psychedelics act as highly efficient power tools for intention: The Self is assisted by their ability to loosen ego parts (e.g. depression, fear of failure, etc.) that are getting in the way.
Can I use ketamine while taking other mental health medications? Is it recommended for any disorder?
Because ketamine acts on NMDA (glutamate) receptors rather than serotonin receptors, it has the distinct advantage over some other psychedelics (such as psilocybin and MDMA) of being safe to use if you already take an SSRI or SNRI medication. This avoids the dilemma of having to taper off these prescribed medications beforehand, which can result in potential ''discontinuation syndrome'' effects that have been known to continue affecting people even after a positive psychedelic macrodosing experience. GABA receptor agonists such as Lamictal or the benzodiazepines can also be used safely along with ketamine if the dose is adjusted accordingly.
Ketamine treatment can be useful for most mental health disorders, but it is not recommended if you have schizophrenia or or unstabilized bipolar disorder. Even if you feel stable on bipolar medication, you should discuss potential risks, and the cost-benefit ratio of treatment, with your prescriber.
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 the NMDA receptor antagonism effect 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, there are numerous psychological patterns that can only be reshaped by new behaviors, routines, and positive connections with others. Ketamine does definitely assist with ego maturation that chronic substance abuse arrests, but it's unlikely to be a full substitute for the lifestyle efforts that build maturity naturally.
As noted above, certain physical health conditions are contraindicated, and this would be discussed with a Wellward Medical healthcare provider first. Trying 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 an overall plan, including cost), establishment of a safe relationship in therapy sessions prior to actual ketamine treatment, and a physician's oversight of all the medical aspects.
As the therapist in the process, I would be honored to hear your story and facilitate your change.