Verena Socolar, PLLC, will offer ketamine assisted psychotherapy starting in Spring of 2024.  Here are some answers to questions you may have about ketamine.

What is Ketamine?
Ketamine is a medication that has been safely used since 1970 when it was first approved for use in anesthesia by the FDA (Food and Drug Administration).  It is also used “off-label” for sedation, treatment of pain, and several mental health conditions.  “Off label” refers to the practice of prescribing a drug for a different purpose than what the FDA approved. This practice is called “off-label” because the drug is being used in a way not described on its package insert. This insert is known as its “label”.  Off label use is a common practice for many medications.   There have been several clinical studies suggesting that ketamine is an effective treatment for depression, Post Traumatic Stress Disorder (PTSD), and other psychiatric diagnoses. 

Esketamine with the brand name Spravato^® has been approved by the FDA for treatment resistant depression in 2019.  Esketamine is a subtype of ketamine, or more precisely for those who understand chemistry, it is the active enantiomer of the racemic Ketamine mix.  

Ketamine is also often described as a dissociative anesthetic that has hallucinogenic effects.   It distorts sensations of sight and sound. It can create non-ordinary states of consciousness (NOSC), and people report psychedelic experiences when taking medium to higher doses of Ketamine.

How does Ketamine work?
The prevailing view is that Ketamine has a rapid effect on neuroplasticity.  Ketamine helps the brain to regrow synapses and increase connectivity.   It is believed that this happens by Ketamine blocking the NMDA receptor, which results in a surge of glutamate.  Glutamate is a major excitatory neurotransmitter (or signaling molecule) in the brain.   Glutamate binds to the AMPA receptor.  This leads through a cascade of events to the release of important growth factors and proteins, e.g. brain-derived neurotrophic growth factor.  These growth factors and other proteins promote healthy brain circuits by increasing the number of synapses and strengthening existing synapses, helping the brain to make better connections and enhancing communication within brain regions.  (Of course, this is a very simplified neuroscience version of a complicated and complex process that is still not fully understood.)  There is little information or understanding about how ketamine causes changes in perception and psychedelic experiences.

What is the difference between ketamine infusion and ketamine assisted psychotherapy (KAP)?
Since the early 2000’s, an increasing number of ketamine IV-infusion clinics in the USA provide off-label treatment for depression (particularly treatment-resistant depression or TRD).  These clinics typically use a biomedical model, relying solely on the biochemical effects of ketamine.  Ketamine is administered via IV-infusion at a low or sub-anesthetic dose over approximately 40 minutes while the patient is sitting in a reclining chair and is tethered to an IV pole and blood pressure and cardiac monitors.  Medical technicians or nurses monitor the patient and medical equipment that remains at the chair-side.  The patient is typically discharged one hour after the infusion ends, and there is little opportunity to process the experience.  Clinics that offer Spravato^® treatment function in a similar way, except that Spravato^® is administered as a nasal spray.  Patients still remain in the clinic to be monitored for possible side effects and safety for about 2 hours before they are discharged.  Psychotherapy and psychotherapeutic support are not typically a consideration in IV ketamine infusion clinics or clinics that offer Spravato^®.

Ketamine-assisted psychotherapy (KAP) takes a different approach to the treatment of depression and other mental health disorders.  In KAP, a therapist will stay with the client during the time the medication is psychoactive and help the client to process the experience.  There will be also follow-up sessions to integrate the experience more fully into the client’s life situation.  KAP providers most commonly administer ketamine sublingually (the medication being absorbed under the tongue) or intramuscularly (by injection into the deltoid muscle).  Consequently, clients are not connected or tethered to medical equipment during their sessions.  This psychotherapeutic approach seems to be growing in popularity as clinicians and patients realize the benefits of concurrent ketamine administration and psychotherapy.  KAP sessions last typically between one and three hours.   They are provided in a comfortable psychotherapy office setting and often involve use of music to facilitate a deeper experience. 

Raquel Bennett, PsyD, who is the founder of KRIYA Ketamine Research Institute, suggests three paradigms or different models of working therapeutically with ketamine.   There is the Western medical or surgical paradigm, which is best exemplified by the treatment approach in IV-clinics.  The administration protocol is specifically designed to avoid psychedelic properties, which are considered problematic.  The patient has a passive role receiving treatment and is not asked to actively participate other than showing up for appointments.  The antidepressant or therapeutic effects of ketamine are thought to be due to its biochemical properties, and the benefits are explained in terms of molecules, receptors, neurotransmitters and the like.  While the neuroscience showing how ketamine is working in the brain is valuable, it may not be the whole story.

A second way of working with ketamine is to use it as a facilitator for psychotherapy.  Ketamine is administered at a low dose that helps the client to relax and experience some distance, making it easier to talk about difficult topics.  Ketamine is taking typically in the form of lozenges or tablets that dissolve under the tongue, and the client engages in psychotherapy while under the influence of the medicine.   Dr. Bennett termed this way of working with ketamine the psychological and relational paradigm.  Another term used for this model is psycholytic therapy.  The beneficial effects of ketamine in this setting are attributed to it facilitating the processing of difficult psychological material.  There is an emphasis on the psychotherapy process, and ketamine is accelerating this process. 

Lastly, there is a way of working therapeutically with ketamine to purposefully induce mystical and psychedelic experiences.   To do so, the doses are high enough for the client to enter into a notable level of altered consciousness.  Patients report having vivid dream-like visions, they may feel dissolved or disembodied and report having had communications with divine beings or divine energies.  Dr. Bennett refers to working with ketamine in this way as working in a psychedelic or shamanic paradigm.  To induce a psychedelic “journey” is only appropriate for a small group of patients and requires careful preparation.   The role of the therapist is to assure psychological and physical safety of the traveler while ketamine is most active, and then later to help the client to make meaning from their experience and use the experience to move forward and make positive changes in their lives.   Patients must be carefully selected and prepared for using ketamine as a psychedelic.  This kind of experience can get confusing and frightening in the absence of appropriate preparation and support by a trained professional. 

All three paradigms are useful, and there is no one right way of working with ketamine.  If you are considering ketamine treatment, talk with a provider who understands all the models and can help you understand which approach may be good for you. Some people have medical conditions that require that they are closely monitored, and IV-clinics are the best choice for them as the infusion can be quickly stopped should there be medical complications.   In any event, make sure that all your questions are answered before you decide whether ketamine treatment may be right for you and what is the best approach for you.

What about the news report of people dying after using Ketamine?
It is true that there have been increasing reports about people dying after using ketamine.  Most of these tragic events happen in the context of poorly supervised use and typically involve illegally obtained ketamine.  Although ketamine is thought to be generally safe at doses used for anesthesia, misuse can lead to serious problems.   There has been a 349% increase of recreational use in the USA between 2017 and 2022, as estimated from the amounts confiscated by law enforcement and the number of reported ketamine poisonings.  Ketamine belongs to the same group of chemicals as phencyclidine (PCP or angel dust).  It is a drug of abuse monitored by the Drug Enforcement Administration (DEA) and is a controlled substance, subject to Schedule III rules under the Controlled Substance Act of 1970.   Ketamine should never be used except under the direct supervision of a licensed medical provider.  Clients need to be carefully screened for medical and psychological contraindications to minimize risks of complications.  As stated above, when used under proper supervision, ketamine has a good safety profile and has been used over 50 years.

How do I decide whether ketamine is right for me?
Ketamine holds the potential to elicit powerful and sometimes life-changing experiences.  I have heard many people talk about how ketamine changed their lives to feeling positive and hopeful after struggling for years with severe symptoms of depression or other mental health problems.  This is supported by clinical research.  Unfortunately, at least at this point in time, ketamine treatments other than with Spravato^® are typically not covered by healthcare insurance, which means the client has to pay the full amount for the treatment out-of-pocket.  

There are many other treatment options, and ketamine is not considered a first line approach as treatment.  Major Depression, PTSD, and Bipolar Disorders may be treated with anti-depressant medications, tranquilizers, mood stabilizers, and psychotherapy. Electroconvulsive Therapy (ECT), and Transcranial Magnetic Stimulation (TMS) are also in use for treatment resistant depression.   

However, if you feel that more conventional approaches of treatment have not been successful in relieving your symptoms and you are interested in ketamine-assisted- psychotherapy (KAP),  I would be happy to talk with you.  I offer a roughly 10-minute phone consultation free of charge to help you to decide whether KAP is something you want to consider further.    I would be happy to see whether my office would be the right fit for you.   I currently have only limited capacity to offer KAP sessions and hope to increase availability by collaborating with other KAP-trained therapists.

Verena Socolar, PhD, PMHNP-BC, has studied KAP with the Polaris Insight Center in San Francisco, CA and continues to participate in consultations groups offered through the Polaris Insight Center.