Ketamine Assisted Psychotherapy (KAP)
Ketamine is a synthetic pharmaceutical compound, classified as a dissociative anesthetic. It was developed in 1963, FDA approved in 1970, and adopted by many hospitals and medical offices because of its rapid onset, proven safety, and short duration of action. Ketamine is most used in surgical settings due to its excellent safety profile, particularly around breathing/airway management. It has also been used successfully in managing acute and chronic pain conditions due to its analgesic properties.
In the last two decades, ketamine has been increasingly clinically applied at subanesthetic doses as an off-label treatment for treatment-resistant mental health conditions, including Major Depressive Disorder, Post-traumatic Stress Disorder, Obsessive Compulsive Disorder, and others.
Ketamine is a non-competitive antagonist of the NMDA receptor. The present understanding is that ketamine and its metabolites interact with glutamate transmission, resulting in the following changes that appear to play a significant role in its antidepressants effects:
1. Ketamine blocks receptors for glutamate, a neurotransmitter associated with brain excitotoxicity and inflammation.
2. Ketamine enhances neuroplasticity by significantly increasing Brain-derived Neurotrophic Factor, a neurological hormone that promotes the reversal of the loss of neuronal connectivity caused by chronic depression.
3. Ketamine normalizes activity of the Default Mode Network, the brain network responsible for obsessive, negative thinking in depression.
Ketamine can be administered in a variety of ways, including as an intravenous infusion (IV), intramuscular injection (IM), subcutaneous injection (SC), intranasally, or sublingually as a dissolving troche, tablet, or lozenge. Routes vary in the onset, bioavailability, and duration of active effects for each person.
Our practice uses sublingually dissolving tablets that are taken in the office at the beginning of the session. Dosing ranges from 25-400 mg and depends on multiple factors, including client preference, therapeutic goals, prior exposure to ketamine and other psychedelics, body height and weight, and sensitivity. Those without prior experiences are advised to begin with lower doses to build familiarity with ketamine’s effects.
The ketamine experience is characterized by the relaxation of ordinary concerns and usual mindset, while maintaining conscious awareness. This tends to lead to a disruption of negative feelings and preoccupations. 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 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 spiritual growth, and promoting a positive change in outlook.
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. These effects typically start 5 to 10 minutes after ketamine dosing. The peak effects typically last 20 to 30 minutes and then slowly diminish over the next hour. Mild alterations in sensory perception, speech, and motor ability may continue for up to 5 hours.
Two 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 ketamine administration or before all acute effects of ketamine have ceased.
The administration of ketamine may be 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 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 will assist you in processing your experiences and their impact on your everyday life.
Many have found it beneficial to set an intention for each Ketamine session. Intentions can include, for example, alterations in habits, shifts in self-defeating thought patterns, or exploration of spiritual/existential realms. We will work with you to formulate your intention, but we will also encourage you to hold it loosely, 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, often with greater insight into themselves and their lives. We will assist you in integrating your insights into your daily life.
As a byproduct of your experience, you may feel improvement in your emotional state and reduction in symptoms such as depression, anxiety, pain, 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 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 those within the 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.
Our treatment team consists of a licensed psychologist who has obtained specialized training in psychedelic-assisted psychotherapy in collaboration with Skylight Psychedelics. Skylight Psychedelics is a physician owned and operated organization that evaluates and prescribes sublingual ketamine to clients who meet criteria, to be used in their licensed therapists’ offices.
Step 1: Client will meet with a licensed mental health provider for an initial diagnostic assessment. If the provider believes treatment with ketamine will probably be helpful, the provider will refer the Client to Skylight Psychedelics.
Step 2: Client will meet online with a medical provider from Skylight Psychedelics. If ketamine is considered appropriate, the provider with prescribe the patient ketamine to be used in session with the mental health provider.
Step 3a: The pharmacy working with Skylight psychedelics will ship the ketamine directly to the patient.
Step 3b: Client will meet with a licensed mental health provider for a preparation session. During the session, the provider and Client will clarify the Client’s goals, provide psychoeducation and instructions for the ketamine treatment, and instruct Client in skills that may be used during the ketamine treatment.
Step 4: Client will check their blood pressure and pulse/oxygen saturation using a pulse oximeter. Client will then self-administer ketamine by allowing it to dissolve slowly under their tongue. Saliva should be held for at least ten minutes to assist with absorption.
While it is safe to swallow ketamine, we recommend holding it in your mouth to increase its bioavailability and effectiveness, and then spitting it out to reduce the risk of nausea.
The first dose will be used to measure your responsiveness. Subsequent dosing will be determined in collaboration with the physicians at Skylight Psychedelics. A sublingual dose provides a peak experience for 20-50 minutes.
Throughout the ketamine sessions, your provider will be present to support you by playing soothing music, guiding you through relaxation exercises, and providing nondirective reassurance. You will be offered an eye mask to help you maintain an internal focus while experiencing the active effects of the ketamine. You will have the opportunity to share your experience once the effects of the medicine subside.
The provider will reconnect with you when you return from the most active phase of your journey and are ready to communicate with the outside world. The moments following an altered state can be exquisitely poignant and powerful in their ability to evoke and reshape how we attach to others; we regard this opportunity with the importance it deserves. We will welcome you to share your experience and discuss any insights that you discovered.
Following each of the ketamine administrations, you will need to stay with us for at least two to three hours. After two hours, we will assess whether you are safe to return home; people can vary greatly in terms of how quickly the effects clear, so your departure time may vary.
Please arrange for a trusted person to pick you up and take you home. We cannot release you to a taxi or car share service (i.e., Uber/Lyft) driver, and we ask that you not drive at all on the day of your administration.
Ketamine treatment can result in several benefits, and there are many studies demonstrating its efficacy; however, it is still a relatively new and experimental psychiatric intervention, and no outcomes are guaranteed.
Ketamine is distinguished from other psychotropic medications by its rapid onset, often producing relief in as soon as a few hours. The literature indicates a 70% initial response rate to ketamine. Durable improvement generally occurs with more than one administration and is most robust when part of a comprehensive treatment plan. It may not permanently relieve your condition. If your symptoms respond to ketamine, you may still elect to be treated with other medications and ongoing psychotherapy to reduce the possibility of relapse.
Ketamine treatment will begin with two sessions a week for three weeks. Over time, you may also need additional ketamine “booster” sessions or other therapies to maintain your remission.
Before participating, you will be carefully interviewed to determine if you are a good candidate for ketamine treatment. This will include discussing your medical and psychiatric history, reviewing your medical and psychiatric records if necessary, and consulting with your primary care provider. You are required to be under the care of a primary care provider throughout the time that you are receiving Ketamine-Assisted Psychotherapy.
Ketamine is contraindicated with certain medical and psychiatric conditions. These conditions include hallucinations, mania, unstable heart disease, uncontrolled hyperthyroidism, uncontrolled hypertension, increased intracranial pressure, liver disease, allergy to ketamine, pregnancy, and breastfeeding.
Ketamine has an extensive record of safety, but as with any medication, there are potential risks and side effects to consider.
The most common physical side effect is a short-term increase in blood pressure, pulse, or heart rate, which may be a risk to those with heart disease and can be misinterpreted as a symptom of anxiety. Other possible side effects include dizziness/lightheadedness; sedation; impaired balance and coordination; slurred speech; mental confusion; excitability; diminished ability to see, hear, or feel stimuli accurately, including one’s own body; headache; anxiety; nausea; and vomiting. These effects are transient and resolve as the medication wears off (typically within 4 hours).
Repeated, high dose, chronic use of ketamine can cause urinary tract symptoms, permanent bladder dysfunction, or cystitis. These adverse effects are generally associated with abusive use of the drug and are much less likely when using ketamine under medical supervision. Please inform your providers immediately if you notice any of these side effects.
Ketamine can worsen psychotic symptoms in people who suffer from schizophrenia or other serious mental disorders. It may also worsen underlying psychological problems in people with severe personality disorders and dissociative disorders.
Our setting and our client instructions (see KAP Preparation and Aftercare Guide for details) are intended to minimize ketamine’s adverse side effects as much as possible.
It is important to abstain from eating or drinking in the 4 hours prior to your treatment to minimize the risk of nausea and vomiting. Additionally, due to possible blurred or altered vision and impaired balance and coordination, you will be advised to lie still and keep your eyes closed or covered with an eye mask until the main effects have worn off.
Some people report the psychic experiences as bizarre or frightening, while others describe them as pleasurable, joyful, or fascinating. We have found that even frightening experiences can be of paramount value to your transition to recovery from the suffering that brought you to us. We are trained in providing stability for those experiencing extreme states, and you will receive psychotherapeutic help and ongoing guidance to make the best use of these experiences.
We reserve the right to activate emergency response systems (such as calling 9-1-1) if it is determined by clinical judgment that your safety requires a higher level of care than can be provided in our setting.
Ketamine belongs to the same group of chemicals as phencyclidine (Sernyl, PCP, “Angel dust”). These compounds are known chemically as arylcyclohexylamines and are classified as hallucinogens (also known as psychedelics). 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 because they do not cause tolerance and withdrawal symptoms. However, cravings have been reported by individuals with a history of heavy psychedelic drug use. In addition, ketamine can have effects on mood (feelings), cognition (thinking), and perception (imagery) that may make some people want to use it repeatedly. Therefore, ketamine should not be used outside the direct supervision of a licensed provider.
There are numerous alternative treatment options that have demonstrated efficacy. These include psychotherapy, psychotropic medications, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), and practices such as yoga, meditation, and prescribed exercise.
Claims will be submitted to your insurance to cover some of the cost of KAP. There may be an out of pocket expense which can be discussed with your provider.