Ketamine Therapy in SF

Ketamine Therapy: A Paradigm Shift

Freud’s “talking cure” began as a therapeutic practice of meaning making, linguistics, and interpretation. The integration of ketamine therapy into the psychotherapy frame offers many innovations. This integration has the potential to move therapy towards becoming a deeper relational, somatic, and experiential practice. Ketamine therapists utilize a number of methods that involve focused attention, breath, movement, supportive touch, and body work; Sensorimotor Psychotherapy, Somatic Experiencing, Holotropic Breathwork, and Hakomi release sensations, pains, emotions, and memories. These interventions treat the entire person by using the body’s innate wisdom to make connections between psychological symptoms, somatic experiences, and physiological states (Mithoefer, MAPS Bulletin Special Edition). The incorporation of ketamine therapy and these techniques into psychotherapy treatment will provide patients with new perspectives and a “direct experience of seeing [oneself] in a new way” (Dore et al, 2019).

The clinical use of ketamine will also change how therapists create the facilitating environment. This will be a departure from how most psychotherapists approach the clinical situation. The attention to set and setting in psychedelic work puts the therapist in the role of not only being a container for the patient’s subjective experience, but also a curator of the entire experience. Creation of the setting includes the incorporation of music and other creative, artistic, and spiritual elements into the space. This gives the ketamine therapist more stewarding control over the environment and more creative influence in the construction of the psychedelic space. It results in a more active approach to holding the patient and developing the “facilitating environment.”

While therapists may gain more control in the development of the setting, the patient of ketamine therapy assumes a greater position of power in the therapeutic relationship. The patient’s “inner healing intelligence” (MAPS Handbook, Inner Healing Intelligence) guides the medicine work; this is an innate wisdom that patients use to lead their healing process. By empowering the patient to lead the direction of treatment, the patient gains more agency and the therapist-patient relationship is more egalitarian. The amplification and speed of transformation in ketamine therapy requires the therapist to have a greater capacity to tolerate the unknown, to trust the process, and to believe in the patient’s inner wisdom. During medicine sessions, the ketamine therapist is often simply bearing witness to the patient’s healing process.

Mithoefer, M. MDMA-Assisted Psychotherapy: How Different is it from Other Psychotherapy? MAPS Bulletin Special Edition

Dore et al. (2019). 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, https://doi.org/10.1080/10481885.2022.2107855

MAPS Public Benefit Corporation (2020). MAPS Handbook

The Use of Touch in Ketamine Therapy

During the beginning of Ketamine Therapy treatment, the provider should review touch, consent for touch, and initiation of touch. Ketamine Assisted Psychotherapy (KAP) providers should inform patients that they can decline consent for touch and that it is not a mandatory component of treatment. Clinicians should assess four areas before engaging in touch: context, intent, consent, and competence (MAPS Handbook, Integrity). Somatically trained KAP providers can engage in touch to facilitate a type of somatic transformation by unlocking stored traumas, memories, and unsymbolized experiences. Ketamine therapists who do not have training in this area should only use touch to establish safety and connection, and to communicate presence and support.

Psychedelic doses in Ketamine Therapy can be euphoric and or terrifying and they require a particular kind of emotional holding. Winnicott (1960) describes his concept of maternal holding as the process of both holding the infant physically and providing a protective and nurturing environment, so that the infant’s sense of “going on being” can evolve. During psychedelic doses in Ketamine Therapy a deep regression can occur where the patient’s temporal and psyche-somatic experience can become disorganized. These moments require a type of holding of the infantile kind and this may include touch. The ketamine therapist must quickly decide to make physical contact with a patient who is having this type of psychedelic experience and will not immediately understand the effects of one’s touch. The clinician must retrospectively process the moment of touch to determine whether it facilitated or encumbered the therapeutic process (Fossage, 2000).

Fossage, J (2000). The Meaning of Touch in Psychoanalysis, Psychoanalytic Inquiry, (20)(1):21-43.

Winnicott, D.W. (1960) The Theory of the Parent-Infant Relationship. International Journal of Psychoanalysis, (41):585-595.

A Description of a Ketamine Therapy Medicine Experience

Ketamine-induced states of mind intensify sensory input from both the psyche-soma and the outside world, and they direct focus on the present moment. These states exist on a continuum. Milder forms of ketamine-induced states can soften psychological defenses, surface repressed memories, and connect a person to unfamiliar, or even unknown, parts of the self. During these milder forms of ketamine-induced states a person’s awareness stays within the boundaries of the body. Conscious awareness stays relatively organized and contained by autobiographical memories and self-representations. These ketamine-induced states may include: flooding of intense emotions and memories; increase of somatic, bodily, and tactile awareness and sensations; spaciousness and clarity of mind; increase of insight and compassion; feelings of peace, serenity, and sacredness; and intense visions.

Ketamine Assisted Psychotherapy (KAP) utilizes both low and high doses of ketamine. At lower “psycholytic” doses of ketamine, a person enters an “empathogenic experience” or trance state, where one’s body relaxes and ego defenses loosen. The person feels an increase of love, compassion, and empathy towards oneself, similar to the effects of a regular dose of MDMA (Kolp et al, 2014; Dore et al, 2019). Since the ego remains intact, ketamine-induced psycholytic states are useful during a Ketamine Therapy to relationally process traumas and developmental arrest. A person may enter a state of “new mind” that is creative, open, and free of obsessional burdens (Wolfson, 2016). Higher “psychedelic” level ketamine doses are more similar to moderate to high doses of LSD, psilocybin, or ayahuasca. The person enters a “transformational state” that has dissociative and disembodied effects (Dore et al, 2019). These doses may completely dissolve the ego including the boundaries between self and other, past and present, and inner and outer. These experiences come with a “rectification of narcissism” by balancing a person’s personal and universal proportions. They can be leveraged later in Ketamine Therapy and integration to increase cognitive and emotional flexibility and reduce negative or inflated ego functioning (Wolfson, 2016).

During ketamine-induced non-ordinary states of consciousness (NOSC), a person may experience vivid dreams, memories, or visions of the future. Re-experiencing birth is common and contact is frequently made with the mythical, the extraterrestrial, deceased ancestors, or archetypal figures. Experiences of reliving one’s entire life, psychological death, and rebirth also frequently occur (Kolp et al, 2014). Providers of Ketamine Therapy should have significant personal experience with ketamine-induced NOSC to become familiar with the arc of the ketamine journey and the way it feels. They must become accustomed to the many different domains a person can travel through during psychedelic states, such as the intergenerational space of ancestors, the evolutionary space of biology, and the mystical space of spirituality and the cosmic.

Kolp et al. (2014). Ketamine psychedelic psychotherapy: Focus on its pharmacology, phenomenology, and clinical applications. International Journal of Transpersonal Studies, 33(2), 84–140. International Journal of Transpersonal Studies, 33 (2). http://dx.doi.org/10.24972/ijts.2014.33.2.84

Wolfson, P (2016). Opportunities and Strategies for a Ketamine Psychotherapeutics (KAP). In: The Ketamine Papers. Saline, MI: MAPS, 2016. 339-359.

How the History of Ketamine Therapy Developed the Current Protocol for Ketamine Assisted Psychotherapy (KAP)

Prior to the development of Ketamine Therapy, a medical ketamine treatment model without a psychotherapeutic component, was prescribed for Treatment Resistant Depression (TRD). It consisted of the administration of intravenous ketamine six times over the course of two weeks. Since ketamine has a long history of clinical safety for many decades, ketamine quickly transitioned to being used as an adjunct to psychotherapy in non-medical, office settings. Intramuscular, nasal, and sublingual forms of administration began to be utilized. Not only limited for patients with TRD, Ketamine Assisted Psychotherapy (KAP) is also currently being used for patients suffering from a variety of diagnoses (See Dore et al, 2019, pg 190).

The current practice of Ketamine Therapy that many practitioners are trained in is adapted from the MDMA-assisted psychotherapy model and protocol created by MAPS. This model combines biological, psychological, and transpersonal elements. During the preparation sessions, the providers obtain informed consent, conduct a psychological and medical evaluation, and review safety protocols. Typically, there are three to six ketamine medicine sessions which are supported by a number of preparatory and integration sessions. However, as the process unfolds, the patient and clinician ultimately determine the appropriate number of medicine sessions. Ketamine Assisted Psychotherapy medicine sessions are 3-hours long, can occur weekly or biweekly, or can be separated by weeks or even months. The cadence is determined by the length of treatment, the presenting issue, level of functioning, and severity of symptoms. This protocol can be offered with a patient who is already in traditional psychotherapy with the same provider or it can be modified to stand alone. The sublingual route of administration, which is the route of administration that used in most private practice settings, typically last 1-2.5 hours in duration. The peak of the experience occurs around 30 minutes after administration is complete.