KETAMINE ASSISTED PSYCHOTHERAPY (KAP) TREATMENT INFORMATION
Commonly Asked Questions
WHAT IS KETAMINE?
Ketamine is a psychoactive compound that has been valued for its long safety record of use in medical settings. Classified as a “dissociative anesthetic,” ketamine is a medication that has historically been used safely as an analgesic agent with demonstrated efficacy in both surgical settings and pain management, since its approval by the FDA in 1970. Ketamine is now an “off-label” treatment for various chronic “treatment-resistant” psychological conditions. The term “off-label” refers to the legal use of a pharmaceutical for an application not originally expected, and/or innovative purpose. A Schedule III controlled substance (and medication), ketamine belongs to a group of chemical compounds (Arylcyclohexylamines) classified as hallucinogens (also commonly known as psychedelics). Unlike most other anesthetic agents, this class of chemical compound/medications is not generally known to entirely extinguish consciousness, but instead is known to significantly dissociate the mind from the body.
HOW DOES KETAMINE WORK?
In general, the most probable mode of action of ketamine is as an NMDA antagonist working through the glutamate neurotransmitter system; this particular neural-pathway is quite different from other mainstream psychiatric medications such as SSRIS, SNRIS, lamotrigine, major tranquilizers (antipsychotic medications), and benzodiazepines. Some feel   that over time ketamine helps to retrain the mind, brain, and personality system to become more relaxed, flexible, creative, and self-compassionate. Psychedelic induced and enhanced neuroplasticity effects in the brain may play a part in the types of positive cognitive, personality and behavior shifts that ketamine and KAP foster. Verbal, emotional and relational processing/integration during and after ketamine sessions seek to maximize the beneficial effects of neuroplasticity.
It is important to note that ketamine’s psychedelic effects (i.e., generally at higher doses) are not necessary for an antidepressant response or for response to emotional and psychological conflicts and difficulties. However, a minimal trance state (i.e., at lower doses) is viewed as essential to successful treatment of all conditions. Low dose ketamine appears to have a cumulative antidepressant effect over time regardless of the route of administration.
WHAT IS KETAMINE ASSISTED PSYCHOTHERAPY (KAP)?
Ketamine assisted psychotherapy (KAP) refers to using ketamine as a way to enhance the therapeutic process. Our therapeutic approach promotes inner directed focus, which is facilitated by supportive and non-intrusive therapeutic inquiry, a safe and comfortable setting, and music. At Catalyst we are aligned with the practices of specific leaders in the field who believe ketamine sessions are most effective when paired with brief and/or ongoing psychotherapy. Our treatment protocol includes instructional preparation before ketamine administration, specific and strategic guidance during sessions, and, most importantly, assistance in integrating the experiences afterwards. We seek to understand our patients unique issues, struggles, hopes, desires, and specific intentions and goals for the treatment. As Wolfson eloquently describes, KAP therapists “serve as refuge makers, guides, interlocutors, who support new mind and the contextualizing of new ways of being; the therapist’s presence supports the here-and-now freedom to refresh, renew, release, and start again, and in the best of conditions and circumstances, a kind of rebooting of the mind, heart, and spirit.”
As previously mentioned, a ketamine treatment session has the potential to create a non-ordinary state of consciousness that can facilitate a profound transpersonal or mystical experience. These types of “peak experiences” have been shown to expand one’s sense of self and the understanding of one’s existence. Ketamine may also enable an individual to access his or her own inner healing intelligence - an intuitive inner guidance system - that can prompt specific actions or solutions based on the individual’s vast interpersonal history and the myriad of options for “moving forward.”
Essential to this method is a time-out from one’s usual day-to-day life and mental experience. The process is characterized by deep relaxation and disengagement from ordinary concerns and usual mindset, while maintaining conscious awareness. Many feel this benevolent disruption of the busy or distressed mind, along with its ruminating preoccupations and concomitant negative feelings, creates an open space for the exploration of new feeling states and self-observations. This process can potentially lead to significant shifts in overall well-being and understandings of oneself and others
Initial sessions involve an assessment of current problems, concerns, needs, and goals, as well as an evaluation of the patient’s overall health, as part of determining the suitability of KAP treatment. At the end of the evaluation period, we offer our clinical impressions and treatment recommendations. The resulting goals of therapy are arrived at by mutual collaboration. These goals will be reviewed across the course of the collaborative work in order to assess and/or modify the treatment according to changing needs and perspectives.
WHAT ARE ROUTES OF KETAMINE ADMINISTRATION?
The routes of administration of ketamine are intravenous, intramuscular, intranasal, sublingual, and oral. With sublingual administration, it generally takes about 20 minutes to begin feeling the drug effects, which last for 45 - 60 minutes. With intramuscular administration (IM), it generally takes 3 -10 minutes to begin to feel the effects, which then subside after 45 - 60 minutes. Verbal, emotional, and interpersonal processing may take place throughout the session or after the stronger effects of ketamine wear off. After the drug’s stronger effects wane, most people generally feel remarkably open, relaxed, vulnerable, and connected to the recently accessed psychological, emotional, and transpersonal material.
WHAT ARE THE POTENTIAL BENEFITS OF KETAMINE?
Participation in ketamine therapy can result in a number of benefits, but there is no guarantee that any or all benefits will occur. Although there are now many studies demonstrating its efficacy, use of ketamine is still considered a new and experimental psychiatric treatment. Improvement generally occurs with ongoing administration (often a combination of in-office and at-home sessions) and is most robust when part of an overall psychotherapy treatment program. KAP may permanently relieve an individual’s condition but not always. If symptoms respond to ketamine, a patient may still elect to be treated with other medications and ongoing psychotherapy to reduce the possibility of relapse.
The literature indicates a 70% initial positive response rate to ketamine, as well as a 40- 50% remission rate (return of symptoms) for patients with treatment-resistant depression. If a patient responds with mood improvements after six initial treatments, he or she may choose to receive additional booster treatments periodically if determined by the treatment team.
WHAT DOES A KETAMINE SESSION LOOK LIKE?
On the day of the ketamine treatment, the patient should follow the directions given by the treatment team about food and medication intake.
During the pre-dosing intake session, the patient and therapist reflect on the specific goals for treatment and facilitate the setting of specific intentions for the ketamine sessions. In general, we also encourage patients to hold these intentions lightly, as attempts to overly control the experience can sometimes prompt unnecessary anxiety and stand in the way of surrendering to the experience. If desired, the patient will collaboratively create a personal invocation, a set of emotionally evocative and relevant statements to be read as the ketamine treatment begins. This “ceremonial” invocation is meant to induce a receptive mindset for the journey. The therapist may also offer and teach breathing exercises and other mindfulness or meditative guidance to address any anxiety the patient may have going into the experience.
The therapist and patient will also discuss, and make choices for, the use of music during the treatment session. Music serves to ground, support, and deepen the process.
Carefully arranged music can provide a sense of forward movement and a guiding flow that can enhance the experience. We provide specially curated playlists, designed to catalyze the psychological and emotional process, and take the patient on an inner journey.
Patients are invited to use an eye mask (a comfortable blindfold) to help maintain an internal focus which facilitates and enhances the experience. Much of the session will be spent “going inside” or focusing on one’s internal experience. However, the therapist will check in periodically throughout the session and may ask questions or underscore themes from time to time. There will be an opportunity to dialogue further once the effect of the medicine subsides.
A condition for KAT treatment, patients are asked to make two important agreements: 1) To follow any direct instructions given by the therapist(s) until the end of the session, and 2) To remain at the office until the therapist(s) determines that the patient is safely ready to leave. Although ketamine has a long safety record, it is a psychoactive drug. Therefore, it is essential that patients are closely monitored and evaluated during and after their treatments to ensure optimal safety upon leaving the clinic.
WHAT DOES KETAMINE FEEL LIKE?
The psychological effects and sensations of Ketamine vary with the dosage and route of administration. The dosage is selected based on patients’ goals and treatment plan.
Some of the physiological effects experienced during KAP sessions include changes in perception of, and sensitivity to, light and sound. Under the influence of ketamine, people commonly describe experiences of lightness, floating, and drifting and reduced control over willful motor functions such as speaking or walking. These phenomena are often experienced with amusement or relief.
At the dosage levels we use, individuals may or may not always maintain conscious awareness of where they are or remain responsive to their surroundings; even at lower doses, some patients have out of body or transpersonal experiences. The session will last approximately two to three hours. The KAP therapist is always present to provide grounding, safety, and support whenever necessary. In general, we suggest patients plan on spending approximately three hours at the clinic on the day of a treatment, although this time may vary.
WHAT ARE THE SIDE EFFECTS?
Ketamine has an extensive record of safety and has been used at much higher doses for surgical anesthesia without respiratory depression. As with any medication, there are also some potential risks and side effects to consider before the treatment process. Set and setting at is intended to prepare patients for (and to minimize where possible) some of the associated psychological side effects. These side effects of ketamine may include distorted visualization of colors, feeling suspended in space or floating, falling sensations, experiencing out-of-body sensations, vivid daydreaming, and unusual changes in sensory perceptions, most often visual, tactile and auditory processing. Familiar music may seem unrecognizable, and new music may seem uncannily familiar. Synesthesia (a mingling of the senses) may occur, such as seeing music or tasting a color. One’s normal and ordinary sense of time may distort with time dilation, telescoping, or contraction.
Some other effects may include dizziness/lightheadedness, sedation, slurred speech, mental confusion, excitability, diminished ability to see things that are actually present, diminished ability to hear or to feel objects accurately including one’s own body (i.e., a sensed distortion of one’s body, the room, or objects), a heightened awareness of physical functions such as respiration, headache, anxiety, nausea. Vomiting is a possible, but an extremely rare, side effect.
Driving an automobile, operating machinery, or engaging in physical activities that are potentially hazardous should not be undertaken on the same day of the dosing session.
Repeated high-dose, chronic use of ketamine has been known to cause urinary tract symptoms in some individuals, and even permanent bladder dysfunction; this has not occurred in our practice. In terms of psychological risk, ketamine has been shown to exacerbate certain psychotic symptoms in people who suffer from schizophrenia or other serious mental disorders and it can potentially aggravate other serious mental disorders such as severe personality and/or dissociative disorders.
With higher doses of ketamine, while most people describe the psychological and transpersonal perceptions as pleasurable, joyful, or fascinating, some people report the unusual experiences as bizarre or frightening. We have found that frightening experiences can be therapeutically very valuable, and ultimately redemptive. We encourage patients to take a nonjudgmental attitude towards all that they may experience during KAP sessions because in general, psychedelic-assisted psychotherapy traditions tend to view so-called “challenging” experiences as harbingers of important breakthroughs that can lead to significant improvements in depression, perspective, mindset, and interpersonal relations. All patients receive psychotherapeutic support and ongoing guidance from the therapists for making the best use of both positively- and negatively-charged perceptions and experiences.
HOW FAST DOES KAP WORK?
Ketamine is a short-acting, with a rapid onset and a potential to elicit transformative experiences, in higher doses it can be a powerful psychedelic. Ketamine has a proven safety record as a dissociative anesthetic used by thousands of patients in much higher doses than are used in our clinic’s psychotherapeutic setting. The immediate or rapid relief of depressive symptoms has a potential for providing an acute interruption of suicidal intent.
Successful treatment of extremely severe symptoms may require more frequent sessions and/or higher doses of the drug at the beginning of a series of sessions, followed by lower-doses and/or less frequent sessions as treatment continues.
HOW MANY SESSIONS WILL BE NEEDED?
The number of sessions needed is variable, depending on overall treatment goals and responsiveness to the treatment. Current research shows that 70% of patients with treatment resistant depression respond positively to 1-3 administrations, and 30-60% report having a remission of their depression for varying lengths of time. It seems that with repeated drug sessions, and in combination with psychotherapy, there is a cumulative antidepressant effect. KAP may also prove effective at reducing remission rates/frequency for symptoms of other conditions such as anxiety and trauma. KAP may further serve to support and foster lasting positive influences on an individual’s interpersonal relationships, occupational and social relationships, and promote the further maturation of an individual’s positive sense of self, self-agency, and self acceptance.
IS KETAMINE ADDICTIVE?
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 compounds that do not meet criteria for chemical dependence. This is because they do not cause tolerance and withdrawal symptoms. However, cravings have been reported by individuals with the history of heavy use of psychedelic drugs. In addition, ketamine can have pleasurable effects on mood (feelings), cognition (thinking), and perception (visual and auditory) leading some individuals to want to use it repeatedly. Therefore, ketamine should only be used under the direct supervision of a licensed physician.
ALTERNATIVE PROCEDURES AND TREATMENTS
Major Depression (MDD), PTSD and Bipolar Disorders are usually treated with antidepressant 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. Currently, no other available medication or procedure for treatment of mood disorders matches or exceeds KAP’s effectiveness and safety when administered properly.