Methods and Practices of Ketamine-Assisted Therapy: Comparing the Medical Model with a Transpersonal Perspective

Abstract

This essay will outline the main existing paradigms of legal ketamine treatment for depression and various other mental illnesses, and discuss the implications of each model. The focus of this composition will be the difference in ideology between two archetypes, in which I will compare and contrast the risks and benefits of these standards. In my research, I found that the medical model and the transpersonal model differ greatly in their philosophy on why ketamine is beneficial for depression. The medical model attributes the healing properties of ketamine to the biochemistry of the ketamine molecule itself, while the transpersonal perspective takes the hallucinogenic effects of ketamine into account, recognizing that its psychedelic properties are a beneficial tool, rather than an unfortunate side effect. In conjunction with transpersonal psychotherapy, integral counseling and/or depth psychotherapy, the consciousness-altering effects of ketamine are a valid and necessary part of the experience that should be studied seriously, as they can lead to breakthroughs in self discovery and deep inquiry into the underlying roots of the patients’ suffering.

Ketamine is a distinctive medicine that is used widely in the medical field as an anesthetic. It is a small molecule that passes easily through the blood-brain barrier through oral, nasal, or intramuscular administration. Since it was first synthesized in the 1960s, and approved by the FDA shortly afterward, it has been used in hospitals all over the world for anesthesia and pain relief.  Ketamine is considered to be extremely safe when used responsibly under clinical supervision, and is even used commonly as an anesthetic in pediatric and veterinary medicine.

 Although ketamine is considered a dissociative anesthetic, it has profound psychedelic and hallucinogenic qualities that are known to produce a mystical experience for those who use it. Under the influence of ketamine, sensory input is muted while the user experiences themselves in a transpersonal realm.

Ketamine is in a unique position, as the only hallucinogenic compound that is currently legal to prescribe and administer because of its necessary role in surgery and healthcare. Its legal status provides researchers and therapists with the prospect of observing a substance-induced transpersonal experience in a clinical setting, without risk of persecution or the hassle of appealing to bureaucratic regulations around studying illegal mind-altering substances. All other entheogens and psychedelics are illegal, with no recognized medical use, according to the FDA.

Originally, the transpersonal qualities of ketamine were completely overlooked by the medical and psychiatric fields due to lack of awareness of the importance of psycho-spiritual experiences and their positive effects on psychological wellness. As interest in the scientific study of psychedelic medicines makes its resurgence, the therapeutic properties of ketamine have been highlighted for their potential effects on treatment-resistant depression. Clinicians have also investigated ketamine treatments for bipolar disorder, suicidal ideation, chronic pain that accompanies depression, and obsessive-compulsive disorder (OCD). Researchers are currently studying the effects of ketamine-assisted therapies for substance use disorders, anorexia, end-of-life anxiety, personality disorders, and post-traumatic stress disorder (PTSD).

Ketamine is a malleable tool, with much variation on how it can be used based on dosage and frequency of administration. The question at the forefront of the ketamine research and therapy field is whether it is legitimate and beneficial to use ketamine alongside talk psychotherapy to facilitate spiritual growth and exploration. There are many ways that clinicians use ketamine to work with patients in a therapeutic context, but this essay will be looking into the two main categorical ideologies around treating patients with ketamine; one, which I will call the medical model, and the other I will refer to as the transpersonal model.

The medical model of ketamine treatment, as we know it today, advocates for the psychiatric use of ketamine for people with refractory (severely treatment-resistant) depression and other diagnosed mental disorders that have rendered the patient unable to function in society. The medical model commonly involves administering around 0.5mg of ketamine mixed with a saline solution intramuscularly, with the amount administered depending on the weight of the patient. The infusion process lasts for about 40 minutes, while the entire appointment generally takes up to two hours.

In order to induce the antidepressant effects of ketamine, patients typically require up to six infusions over a period of several weeks. Although the ketamine molecule itself has not been endorsed by the FDA as a treatment for depression, or anything other than anesthesia, the National Institute of Mental Health (NIMH) and the American Psychological Association have both recognized and published the positive effects of intramuscular ketamine infusions on treating severe depression in cases where the patient is unresponsive to traditional talk psychotherapy and available antidepressant medications.

Another method used within the medical model is a newly patented nasal spray that contains Esketamine, a synthesized enantiomer of ketamine, which has recently been approved by the FDA. Ketamine contains two isomers (molecules with the same molecular formula, but a different arrangement of atoms.) Although both isomers have antidepressant properties, the “R” isomer may induce a feeling of relaxation or elation but has less psychoactive effects, while the “S” isomer is more potent and has dissociative and hallucinogenic properties. The company Johnson & Johnson has patented Esketamine nasal spray, after failed attempts by several companies to create a new molecule with similar properties to ketamine. Esketamine contains a modified, filtered form of S-ketamine. Unfortunately, while generic (racemic) ketamine costs only $1.59 per 100mg, Johnson & Johnson charges $850 per 84mg, leaving it virtually inaccessible to many lower-income patients. It is not covered by most insurance, and the cost does not include the 2 hours of medical supervision that is required for use. (Wood, 2019)

Although studies have shown that R-ketamine may have a more sustained antidepressant effect, (Yang, et. el. 2015) the active ingredient in the new nasal spray Esketamine is derived from the significantly more potent S-isomer. It is important to note that the medical model views these psychedelic qualities as an unfortunate side effect, and treats patients in a way that aims to prevent these experiences from occurring. The goal of treatment under this model is to get just enough ketamine into the patient’s system without producing hallucinogenic effects. Research in this clinical model focuses on the healing properties of the chemical itself, rather than the mystical effects that the ketamine infusion experience can produce.

According to clinical psychologist and ketamine researcher Raquel Bennett, PsyD, this medical model of treatment puts the patient in a passive, rather than active role in their therapeutic process. Under this framework, the patients “aren’t being called to heal themselves, they are just showing up to receive the medicine.” (Bennett, 2019) Since the dosage administered in the medical model is so small and spaced out, the patient will likely experience anesthetic and mild dissociative effects, but will intentionally be prevented from accessing its distinct psychedelic properties.

This brings us to a separate and developing paradigm of available ketamine treatments, ketamine-assisted psychotherapy. This method also involves intravenous ketamine infusions, and is sometimes followed by orally self-administered ketamine lozenges. Like the infusions used in the medical model, (but unlike the nasal spray) racemic ketamine is used, which contains a mixture of both “R” and “S” isomers. The medicine is administered in conjunction with transpersonal psychotherapy, integral counseling psychology, and/or depth psychotherapy. In ketamine-assisted psychotherapy, patients work with a trained psychotherapist before, during, and after their ketamine infusion experience. As opposed to the medical model, the antidepressant effects of the medicine are attributed to the mystical experience induced by ketamine, rather than its biochemical properties alone.

This approach to working with ketamine involves using it as a lubricant for ongoing psychotherapy, in which the therapist builds and develops a relationship with the client. The relaxing and sometimes euphoric effects of ketamine may allow the patient become more open to discussing painful or traumatic material that was previously too difficult to approach with their therapist. Typically, it is self-administered sublingually through a lozenge, or by intramuscular injection of around 0.3-0.8 mg depending on the patient’s size and tolerance level. Depending on the dose, the treatment session can last from 1.5 to 3 hours.

This method works by allowing “patients [to] convey that their understanding or resolution of a difficult issue moves from being intellectualized into an embodied way of knowing.” (Bennett, p. 49) The patient is able to not only think about their trauma, but to process the feelings safely in the presence of their therapist without becoming overwhelmed or re-traumatized. The effectiveness of this process is attributed to the patient’s new ability to consolidate and “digest” previously inaccessible psychological material. The emphasis in this method is placed on the psychological and relational aspects that can be uncovered and worked with in conjunction with the ketamine experience. Most clinicians that use this treatment modality work transpersonally, integrally, and/or psychodynamically in the therapy sessions that accompany the use of infusions or lozenges. Bennett also states that no one other than a trained psychotherapist can provide treatment under this model, which is similar to the current protocol for the MDMA-assisted psychotherapy trials for treating PTSD. “Any other kind of provider [giving ketamine to patients] in any other context is offering pseudo-therapy.” (Bennett, p. 49)

            Within this transpersonal framework lies yet another subset of ketamine-assisted psychotherapy, and unlike the approaches I previously discussed, involves administering relatively high doses to intentionally encourage a mystical experience. The process of approving patients for this type of transpersonal treatment is selective, as not everyone is psychologically equipped or prepared to undergo a strong, psychedelic journey. To induce a ketamine experience at the hallucinogenic level, 1.0-2.0mg of racemic ketamine is injected into the patient intramuscularly in a clinical environment under supervision of a medical professional. The patient experiences a level of sedation that is not quite at the level of full anesthesia—they are still semi-conscious, but may experience a temporary inability to move.

The patient may begin to experience the peak ketamine effects within minutes of the initial injection, “dissolving” into a dissociated, transpersonal realm. Patients who have received this treatment report connection to a divine entity, a higher power, or a spiritual realm. Much like ancient shamanic traditions, this methodology for using ketamine values the hallucinations produced as powerful information that is relevant to the client’s healing process. During the client’s psychedelic ketamine journey, the clinician observes them in order to keep them physically safe. After the strong psychedelic effects have mitigated, the therapist emotionally supports the client as they piece together the meaning of their experience, and holds space while they integrate their newfound knowledge into their daily life in order to make the changes deemed necessary for their mental and emotional health.

All of these methods can be useful—some benefit greatly from the medical model of treatment, others who have difficulty accessing and processing emotions may see improvement with talk psychotherapy lubricated by lower doses of ketamine, and the small amount of patients who qualify for high-dose infusions may reach therapeutic breakthroughs as a result of a ketamine-induced transpersonal experience. Although not everyone is suited for a session that induces psychedelic effects, it is my belief as an advocate for the safe use and study of psychedelic medicines and entheogens that there is inherent value in the visions themselves. The benefits to those who do qualify for high-dose sessions are unmatched, and the results deserve more attention from the psychological field.

The Esketamine nasal spray has received plenty of media attention, but it is a shame that the mystical effects of higher dose ketamine infusions have been mostly ignored by mainstream science. The legality of this medicine provides a perfect opportunity to study the mysterious visions produced and their apparent connection to mood regulation, and we as a field are doing a huge disservice to those who suffer from depression and other mental illnesses by ignoring the undeniable healing effects of the visions induced by this medicine. Many who have had shamanic or psychedelic journeys report their experience to be incredibly informative and life altering, leaving the patient with an expanded sense of connection to life and the universe. Indigenous cultures have known for thousands of years that mind-altering compounds in medicines such as ayahuasca, peyote, and psilocybin mushrooms can produce revelations that can be transformative for personal growth and development. In ketamine lies an unprecedented opportunity to study the advantageous nature of these mystical experiences from a Western clinical lens in a medically safe environment, without appropriating the traditional practices or using up the natural resources of the indigenous people who have taught us the value of working with these medicines.  

It is tricky to study a mystical experience scientifically, because the results cannot always be quantified. However, since both LSD and MDMA experiences have been scientifically investigated and proven to produce psychotherapeutic effects, it is clear that ketamine has similar if not equal potential for inducing these states that can be so helpful in untangling lifelong emotional turmoil. The integration of psychedelics into a mainstream healthcare model could serve to dismantle our biologically driven idea of psychiatry, uniting medical science with the well-known therapeutic effects of ancient wisdom and mysticism.

As stated above, the medical model can be quite favorable to many patients who choose to try Esketamine or ketamine infusions in this context. However, if we continue to focus only on the biochemical effects of this medicine, and intentionally prevent the unique transpersonal properties of ketamine from occurring, we are simply repeating the same methods we have used in the past with a different chemical, and missing out on the vast potential of observing the value of these dreamlike states. If ketamine is truly a breakthrough medicine, we should work with it to its full potential, lest we miss a valuable chance at solving the increasingly pervasive issue of treatment-resistant depression.

As someone who has personally experienced existential depression, used traditional antidepressants with little to no benefit, and eventually received profound and transformative healing from psychedelic medicines alongside transpersonal psychotherapy, I find that the potential of high-dose psychedelic ketamine infusions is an essential factor in transforming the way we view mental health at large. If there is a pathway for accessing the root cause of depression, rather than simply temporarily covering up the symptoms, it should absolutely be investigated as to empower patients to be agents of their own healing rather than keeping them passively dependent on treatments that only temporarily diminish their symptoms.

Ketamine in high doses has this potential, and it should absolutely be used as such, rather than suppressing its unique properties in favor of keeping to an outdated and fragmented medical model that ignores the value of the psychedelic mind state. It is my belief that this opportunity lies within these transpersonal ketamine experiences, and that they should be available and accessible to anyone who qualifies to receive them. Without the acknowledgement of the validity of transpersonal phenomena, ketamine-assisted therapy is simply a mechanism for repeating the same inadequate pursuits. In acknowledging and involving the role of transpersonal phenomena in psychological care, we open the door for a holistic and comprehensive new paradigm of mental healthcare.

Published by maiashmuelipsychotherapy

I am a graduate student, therapist and researcher interested in how altered states of consciousness and spiritual/mystical experiences can be transformative for clients’ mental health. I work with clients of all backgrounds, and provide trauma-informed, harm-reduction oriented care.

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