KAP

Ketamine is a medication that has long been used safely as an anesthetic and analgesic agent. It is classified as a dissociative anesthetic. Ketamine has been used in surgical settings and pain management since its approval by the FDA in 1970. It is now increasingly applied clinically as an off-label treatment for various chronic treatment-resistant mental health conditions, such as depression, anxiety, PTSD, substance misuse and addiction, and other psychiatric diagnoses.

Ketamine was discovered by Cal Stevens of Wayne State University and developed by Parke-Davis (a subsidiary of Pfizer) in 1961. In 1970 it was approved for human use and was initially marketed as Ketlar and was used as an unusually safe anesthetic.  Its use in hospital settings became controversial due to the “emergence syndrome,” a phenomenon involving disorientation and perceptual disturbances when coming out of anesthesia. Some innovative psychiatrists, such as Salvador Roquet, saw the emergence phenomenon as a fascinating principal effect rather than an unwanted side-effect and began using ketamine as an adjunct to psychotherapy. Other psychiatrists, such as Eli Kolp, Evgeny Krupitsky, and Karl Jansen followed, and used high-dose intramuscular ketamine, in combination with psychotherapy, for the treatment of a variety of mental health conditions. In the 1990’s, Dr. John Krystal at the Yale School of Medicine used ketamine as a treatment tool to understand and treat schizophrenia.  The emergence phenomenon is now understood as a potentially desirable effect to facilitate deeper healing through Non-Ordinary States of Consciousness (NOSC).

Routes of administration of ketamine include intravenous, intramuscular, intranasal, and sublingual At Center for Conscious Alchemy, we use sublingual and intramuscular intramuscular routes of administration, and collaborate with our clients in curating the best type and dosage for each client. You will have the option of either using compounded ketamine lozenges or troches (self-administered sublingually and held under tongue for several minutes) or receiving the medicine via intramuscular injection, and we can be creative in experimenting with what works best across sessions.

On the day of your ketamine treatment, please follow the directions given by the treatment team about food and medication intake. You can plan to spend approximately three hours at the clinic on the day of treatment, although this time may vary.

At the beginning of the session, you and your therapist will clarify intentions for your experience. We will encourage you to hold these intentions lightly, as resistance or attempts to control the experience can produce anxiety and stand in the way of the experience. We will also discuss the use of music during the treatment session. Music serves to ground and potentially enhance or guide the experience. We provide playlists designed to optimize your benefit from your treatment session. We will optimize set and setting through the use of invocations, meditative practices, and/or breathing exercises, to support an open, relaxed and growth-oriented mindset, to reduce anxiety and to ease the transition into non-ordinary states of consciousness.

Once the ketamine is administered, you will be encouraged to use an eye mask to facilitate and enhance the experience, and to help you maintain an internal focus. You will spend much of the session “going inside” or focusing on your internal experience. However, your therapist will check in with you periodically throughout your experience and may ask you questions from time to time. You will also have the opportunity to share more once the effects of the medicine subside. Your therapist will take detailed notes on all that you share in order to support recall, insight, and integration.

As the effects of the medicine wear off, you will spend time discussing and integrating your experience with your therapist. On rare occasions when the effects of the medicine last longer than the time allotted, you will be able to recover in the waiting area until your therapist feels it is safe for you to leave.

Most clients are referred to KAP by their primary therapists, other medical providers, and/or family or friends who have heard about this innovative treatment. Many of those who are referred have undergone courses of psychotherapy and/or trials of anti-depressant medications without success. Self-referral also occurs, especially in response to recent media coverage of the benefits of ketamine- and psychedelic-assisted therapies.

It should be noted that some individuals struggling with long-term challenging psychological issues may find themselves directed to KAP therapy by way of current media hype. Eye-catching headlines and sound-bite journalism can create unrealistic expectations that are counterproductive to successful KAP outcomes. KAP is, therefore, sometimes approached with the false notion that ketamine provides a one-off quick-fix mental health shortcut. Some have even incorrectly referred to ketamine as a “happy pill” or a “magic bullet.”

To help protect and promote a productive KAP treatment process, managing expectations is an important consideration. We recommend defining realistic expectations and identifying achievable goals for symptom relief based on:

• understanding and cultivating resilience
• understanding and cultivating meaningful engagement and interconnectedness
• developing heightened compassion for oneself and others
• gaining access to a wider range of feelings (i.e., sadness, joy, grief, wonder, inspiration, anger, etc.) than previously available
• developing cognitive and emotional flexibility
• gaining perspective on one’s identity and history
• working through and releasing unhealthy levels of shame, guilt, and self-defeating beliefs
• developing an appreciation of, and tolerance for, ambiguity and uncertainty
• increasing self-awareness
• improving interpersonal communication and relationships
• enhancing creative problem-solving abilities
• improving self-care and healthy habit formation
• decreasing or discontinuing addictive and self-destructive behaviors

It is helpful to foster realistic expectations for the short- and long-term timeline of KAP’s beneficial effects. Some changes may come in sudden shifts of perspective during a KAP session that may remain long after the session has been completed. Also, it is important to note that some of the most valuable KAP influences and insights may evolve slowly over time with extended integration and reflection. We have found that the benefits of KAP are extended when clients engage in a variety of self-care practices during and after the treatment.

Although ketamine is the catalyst for change, it is actually the therapeutic relationship—with mindful reflection, investigation, patience, and integration—that is the vehicle of transformation. KAP is best approached with the understanding that developing “a resilient and meaningful life worth living” is an ongoing process.

Participation in ketamine psychotherapy can result in a number of benefits, but there is no guarantee that this will occur.

The ketamine experience is designed to enable your own inner healing intelligence to be accessed and guide your process. The psychotherapy relationship will provide safety, support, dialogue, and containment through the course of treatment.

Potential benefits of KAP may include: Improved mood, reduced anxiety, improved stress-management, enhanced self-esteem and resilience, reduced hypervigilance 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, and a wider-angle lens perspective on one’s history, identity, and future.

Ketamine therapy is a new and experimental psychiatric treatment, though there are now many studies demonstrating its efficacy. Improvement generally occurs with more than one administration and is most robust when part of an overall treatment program. It may not permanently relieve your condition. If your symptoms respond to ketamine, you may still elect to be treated with medications and ongoing psychotherapy to reduce the possibility of relapse. Over time, you may also need additional ketamine booster treatments or other therapies to sustain benefits.

The literature indicates a 70% initial response rate to ketamine, as well as a remission rate (return of symptoms) for patients with treatment-resistant depression of 40-50%. If you respond with mood improvements after 6 treatments, you may go on to receive additional booster treatments periodically to be determined by your treatment team.

To read more about the efficacy of KAP for treating depression and anxiety in an outpatient setting, see Phil Wolfson’s in-depth clinical study here.

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 side-effects and risks to consider. Our setting and medical monitoring are intended to minimize ketamine’s side effects as much as possible.

Effects of ketamine may include nausea, brief, transient increase in blood pressure, changes in perception and visual, tactile, and auditory processing, feeling suspended in space or floating, and falling sensations. Synesthesia (a mingling of the senses) may occur. Perception of time may also be altered. Other possible adverse effects may include dizziness/lightheadedness, sedation, slurred speech, mental confusion, excitability, diminished ability to see things that are actually present, diminished ability to feel objects accurately (including one’s own body), diminished awareness of physical functions such as respiration, headache, anxiety, and vomiting (although rare).

Due to risk of nausea and vomiting, patients will be advised to refrain from eating at least 4 hours prior to a session. Due to possible blurred and altered vision, as well as impaired balance and coordination, you will be advised to remain lying down and keep your eyes closed (as long as you are comfortable doing so) or use the eye mask provided until the main effects have worn off. Driving an automobile or engaging in hazardous activities should not be undertaken on the day of the dosing session. You will be assessed for safety prior to leaving the office and will need to have a prearranged ride home.

Repeated, high-dose, chronic use of ketamine has caused urinary tract symptoms and even permanent bladder dysfunction in individuals abusing the drug. This has not occurred in our practice. Neurotoxicity has not been shown to occur in supervised clinical practice; however, in conditions of excessive use over time, mild to moderate cognitive impairments have been noted, specifically regarding memory. While psychological addiction to ketamine has been know to occur in recreational contexts, it is not common in our clinical practice due to lower doses and moderated frequency of administration, psychoeducation about safety, sacredness, and responsible usage, consistent clinical monitoring, and the ongoing trust developed in the therapeutic relationship.

In terms of psychological risks, ketamine has been shown to worsen certain 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.

Some people report that the transpersonal experiences are bizarre or frightening, while many describe them as pleasurable, joyful, or fascinating. We have found that even frightening or overwhelming experiences can be of great value to the healing process, and pivotal in the resolution of the suffering that brought people to seek treatment in the first place.

You will receive ongoing guidance from your therapist in making the best and most meaningful use of these experiences.

Ketamine has a rapid onset and is a short acting powerful psychedelic with the potential of transformative experiences.

Regarding the acute effects of ketamine, with sublingual administration, it generally takes about 10-15 minutes to begin feeling the effects, which then subside in about 60 – 90 minutes. With intramuscular administration, it generally takes 3-5 minutes to begin feeling the effects, which then subside after about 45-60 minutes.

This onset of anti-depressant effects typically occur within 24 hours and has been know to last up to 2 weeks. Ketamine administration has been shown to effectively interrupt acute suicidal ideation in some patients. Repeated administrations over a short amount of time tend to result in more durable and clinically significant effects.

KAP is a non-linear process and relief from symptoms may wax and wane before stabilization of gains is achieved. Effectiveness of treatment can typically be assessed within a few sessions, although with some clients with more complicated psychological conditions, a longer course of treatment may be needed.

The number of sessions is individual depending on overall treatment goals and responsiveness to the treatment. Some patients benefit from only one session, while many benefit from a series of 3-6 sessions, and some come for more ongoing “booster sessions” intermittently over months or years.

Current research on ketamine infusion treatment shows that 70% of patients with treatment resistant depression respond positively to 1-3 administrations, and 30-60% report some remission of their depression symptom for varying length of times. With repeated sessions, there is a cumulative beneficial effect.

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 does have some abuse potential.  Ketamine can have effects on mood (feelings), cognition (thinking), and perception (imagery) that may make some people want to use it repeatedly. Ketamine has been known to be a drug of abuse in recreational settings. However, in clinical practice, given the limited access, psychoeducation of responsible use, and close monitoring, problems with the abuse and diversion of ketamine are rarely seen.

Because of its potential for abuse or psychological addiction, ketamine should never be used except under the direct supervision of a licensed physician.

Music is an essential component of the KAP experience. We use special, curated music playlists that are designed to synergize with medicine effects and support the therapeutic process. Ambient, atmospheric tracks are carefully selected to help patients to deepen into the meditative state of mind and surrender to the experience.

You can listen to some public playlists on Spotify here: