So, what exactly is ketamine?
Ketamine is a psychoactive drug which was developed in 1963, FDA approved in 1970 and has been included in the World Health Organization’s List of Essential Medicines. It is one of modern medicine’s most widely used drugs and has long been adopted by many hospitals and other medical sites due to its rapid onset, proven safety, and short duration of action. Ketamine is most commonly used in surgical settings, including pediatric surgery, because of its excellent safety profile, especially concerning management of airway/breathing.
Over the last two decades, ketamine has been increasingly applied clinically at subanesthetic doses as an off-label treatment for many treatment-resistant mental health conditions such as depression, anxiety, substance misuse and addiction, obsessive compulsive disorders, PTSD and other psychiatric diagnoses.
Ok, but what does ketamine actually do?
Though there is still much to be studied about how ketamine works, the current understanding is that its mode of action is as an NMDA antagonist working through the glutamate neurotransmittor system. This is a different pathway than that of other psychiatric drugs such as SSRIs, SNRIs, antipsychotics, benzodiazepines etc.
As a dissociative anesthesia, ketamine can produce a sense of disconnection from one’s ordinary reality and identity of self. Like other practices that facilitate non-ordinary states of consciousness (NOSC) such as breathwork and meditation, ketamine decreases the default mode network, which is kind of like taking our ego off-line for a bit giving us a break from our inner critic, our protective defenses and all the stories we attach to in our daily routines.
Ketamine offers a means to modify the default mode network, disrupts habitual neural pathways and fosters neuroplasticity. We get to access what lies beneath, the knowing we hold inside, the truths we have shut down due to fear or trauma and return to ourselves.
So what’s the deal with the psychotherapy part?
I believe deeply that healing is a relational process. In KAP, the actual ketamine experience is only part of the whole process which includes preparation with your provider(s), guidance as needed during the experience, and, most importantly, proper integration in the days and weeks following the ketamine session. One piece alone may be helpful to some (just the ketamine treatment or just the psychotherapy) but decades of research confirm that weaving all the pieces together is really where the magic can happen.
The altered states experienced with ketamine can cultivate greater relational and psychological openness. This offers an opportunity for you and your providers to have greater access to the parts and stories that need healing. Because of this, there must be enough safety and trust with your provider(s) before beginning any work with ketamine. The relationship is medicine just as the ketamine is.
Can you tell me what the ketamine experience will feel like?
Yes and no. Everyone’s experience with ketamine is different and each experience you have will likely be somewhat different as well. Different doses and tolerances will impact the experience; prior experience with psychedelics is another variable. It truly is a relationship with the medicine; much depends on proper preparation with your providers to manage expectations and clarify intentions for the experience. (I know, that’s not always a satisfying answer!)
That said, there are some common experiences people have with ketamine, which are often characterized by the relaxation of ordinary concerns and mental constructs/defenses which can lead to the disruption of previously adopted thought patterns.
At lower doses, people often experience mild anesthetic, anxiolytic, antidepressant and psychoactive effects. Some experience increased sensitivity to light and sound and an altered sense of time. Many report empathogenic (heart opening) effects in this dose range. This lower dose state (referred to as a psycholytic experience) allows the individual to maintain the ability to communicate with the psychotherapist but with relaxed defenses which can enhance the therapeutic process.
Higher doses will more likely produce psychedelic, dissociative states during which people are not in communication with the providers but are having a more internal experience. These psychedelic experiences often provide a more robust treatment effect and may assist in the resolution of existential concerns, accelerating psychological and spiritual growth, and cultivating a positive change in outlook and more flexible perspective. The therapy sessions which follow the ketamine experience are important to fully integrating these shifts.
Some sensory effects of ketamine may include distorted visualizations of colors, feeling suspended in space or floating, experiencing out of body sensations, vivid imagery, and shifts in visual, tactile and auditory processing. Some experience synesthesia which is a mingling of the senses.
The effects of ketamine typically start 5-10 minutes after the dose is given (via sublingual lozenge or intramuscular injection). The peak effects generally last 20-30 minutes and then slowly diminish over the next hour. Some alterations in sensory perception, speech, and motor ability may continue for approximately 5 hours.
What are some benefits of doing KAP?
Again, this is different for everyone and there are no guarantees of what the experience will hold for you. This is an important aspect of the preparation work. Because we are in what many are calling “The Psychedelic Renaissance” with regular headlines in the mainstream media, there is a danger of people entering into this process with the belief that ketamine will be a magic bullet to “fix” all the challenges of being human. KAP works for many, and not for others - just like various modalities of psychotherapy and just like many other psychiatric drugs. I believe, however, that there is virtually always something to gain from the experience with ketamine and the integration with your therapist - it just may not be exactly what you wanted in exactly the way you wanted it!
Potential benefits may include:
improved mood
decreased anxiety
improved stress management
enhanced self esteem
increased resilience
reduced hyper vigilance and fearfulness
resolution of trauma
increased engagement with life and interpersonal relationships
reduced existential distress
increased mindfulness
decreased compulsive and addictive behaviors
increased self-compassion
broadened perspective on one’s history, identity, and future
Ketamine therapy is an emerging psychiatric treatment. At this point, we have many studies demonstrating both its safety and efficacy for mental health use. The current literature indicates a 70% initial response rate to ketamine and a remission rate (return of symptoms) of 40-50% for individulas with treatment-resistant depression.
Improvement in symptom relief generally occurs with more than one ketamine experience and is most robust when part of an overall treatment plan. Your ketamine experience may not permanently relieve your symptoms and you may still choose to be treated with medications and ongoing psychotherapy to reduce the possibility of relapse. You may also need additional ketamine booster treatments over time.
Sounds good but are there any side effects?
Ketamine has an excellent safety record and is often used at much higher doses for surgical anesthesia and in emergency rooms for procedural sedation, without a significant risk of respiratory depression. As with all medication, there are potential risks and side effects.
Side effects may include nausea, increase in blood pressure, dizziness/lightheadedness, drowsiness and sedation, slurred speech, blurred vision, impaired balance and coordination, and headaches, all of which tend to resolve within a few hours.
Repeated, high dose, chronic use of ketamine has caused urinary tract symptoms and even permanent bladder dysfunction or cystitis in those abusing the drug. Neurotoxicity has not been shown to occur in supervised clinical practice.
In terms of psychological risk, ketamine has been shown to worsen certain psychotic symptoms in people who suffer from schizophrenia or other serious mental health disorders. It may also worsen underlying psychological problems in people with severe personality disorders and dissociative disorders.