When a new drug is approved for medical use, the manufacturer produces a “label” to explain its use as approved by the FDA. Once a medication is approved by the FDA, physicians may use it “off-label,” meaning for purposes other than what is listed on the label, as long as the use is based on sound medical evidence. Ketamine has been increasingly used “off-label” to treat various chronic and treatment-resistant mental health conditions, such as depression, alcoholism, substance dependencies, post-traumatic stress disorder, anxiety disorders, and other psychiatric diagnoses. 

What is Ketamine Assisted Psychotherapy (KAP)?

KAP is basically psychotherapy with the assistance of ketamine. It is considered a psychedelic assisted therapy and the focus is on the psychotherapy. The ketamine is a tool to enhance therapy. The therapy is done before, during, and after you ingest the ketamine. It is a relatively new approach that arose out of the data coming out of ketamine infusion centers who were seeing improvement in mental health conditions. Most infusion centers are not doing concurrent therapy with the administration of ketamine. 

Though research has demonstrated an antidepressant response to low doses that are minimally psychoactive or sub-psychedelic, this effect tends to be cumulative, requiring repeated administrations over short periods of time. Some practitioners view the psychedelic and dissociative experiences that occur at higher doses to provide a more robust and longer-lasting outcome and we concur. 

We think 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. 

Ketamine has the potential to create a non-ordinary state of consciousness, facilitating a profound transpersonal or mystical peak experience. These sorts of peak 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 serve as guides, and assist in processing the experience and its impact on your everyday life. 

How does Ketamine work?

Ketamine works on a different pathway than other classic psychedelics. Ketamine is an NMDA antagonist and works on the glutamate neurotransmitter system. Other psychedelics and SSRIs work on the serotonin pathway. Because of this, it is not necessary to stop using your SSRIs in order to benefit from ketamine.

How is it administered and at what dose?

Ketamine can be administered in a variety of ways, including as an intravenous infusion (IV), intramuscular injection (IM), intranasally, or sublingually/orally as a dissolving troche or tablet. Routes vary in the onset, bioavailability and duration of active effects for each person. 

In our practice, ketamine is primarily self-administered by sublingual (oral) dissolving tablets, a strategy which may allow for psychotherapy during the treatment, and an easier experience for those who are hesitant about injections. We  adjust the dose, frequency, and time in between sessions based on each individual’s needs. 

The choice of route and dose 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 psychedelic experiences are advised to begin with lower doses to reduce anxiety and build familiarity with ketamine’s effects, while those who are experienced with psychedelics may begin with higher initial doses.

What are treatment sessions like?

We will take some time when you arrive to discuss your current state, and remind us all of your intentions for this work. A small ritual that is individualized to your particular preferences and spiritual practices may be performed as a way to initiate and open the space for the day’s work. 

For sublingual dosing, we will begin treatment with one lozenge at the dose you and your prescriber have decided. It will dissolve slowly, and as the ketamine is being absorbed through the lining of your mouth, you will be asked not to swallow your saliva for at least 15 minutes. You and your prescriber will decide on whether or not to swallow your saliva after the 15 minutes. Swallowing can lead to a deeper experience but it also takes longer to wear off so your plans for the rest of the day or evening should be considered. 

The first dose will give us a measure of your responsiveness to ketamine, and enable us to witness the effectiveness of the lozenges and adjust the dose if needed. Some people experience empathogenic (emotional openness) effects in this dose range, and engaging in therapeutic exploration can be quite fruitful. Others find speaking too difficult and prefer an internal focus even at this lower dose. Your preferences for engagement will be respected. 

After 30 minutes, you may have the opportunity to self-administer a second dose which you will be asked to keep in your mouth for 15 minutes. Each sublingual dose provides a peak effect of approximately 20 minutes. 

Throughout the ketamine session, your provider will be present for support and to guide you through any recommended relaxation exercises, play soothing music, or read your personalized invocation or other previously discussed materials, if desired. During these sessions, it’s recommended you wear an eye mask to facilitate and enhance the experience, and to help you maintain an internal focus. 

Some people are talkative, but many find it beneficial to just stay with that internal focus, as forming words can be challenging while under the influence. You are welcome to share whatever you like, but there is no pressure to narrate your journey. Your provider will take notes of content you do choose to narrate, as it may be relevant to discuss during integration of the experience. You will have the opportunity to share once the effect of the medicine subsides.

Your provider will reconnect with you as you return from the most active phase of your journey, and are ready and willing 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, and your providers regard this opportunity with the importance it deserves. 

You will be welcomed to share about your experience and discuss any insights or alternative perspectives that you discovered; however, some choose to contemplate their experience quietly and discuss at a later integration session. Whatever decision you make in these moments will be respected. 

What does ketamine feel like?

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, and often with greater insight into themselves and their lives. Many people report “psychedelic” effects (feelings of oneness, time distortion, inability to describe the experience in words). 

Though experiences vary greatly, it is generally thought that lower doses provide empathogen-like (heart-opening) responses, while higher doses create dissociative, psychedelic, out-of-body, ego-dissolving peak experiences. Dissociation can feel like detachment from your body, the environment and your usual sense of self.  

The ketamine experience is characterized by the relaxation of ordinary concerns and usual mindset. This tends to lead to a disruption of negative feelings and preoccupations which can lead to significant shifts in overall well-being. 

At lower doses, you will 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 (similar to MDMA) 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 possibly spiritual) growth, and promoting a positive change in outlook and character, this is known as a transformative response. 

Sensory effects of ketamine may include distorted visualization of colors, feeling suspended in space or floating, experiencing out-of-body sensations, vivid imagery, and changes in visual, tactile and auditory processing. Synesthesia (a mingling of the senses) may occur. Familiar music may not be recognizable. An ordinary sense of time may morph into time dilation. 

Some people report psychic experiences, which they perceive as bizarre or frightening, while others describe them as pleasurable, joyful, or fascinating. We have found that even frightening experiences can be of great value to your recovery process. Our team is trained in providing stability for those experiencing extreme states, and you will receive psychotherapeutic help and ongoing guidance as to how to make the best use of these experiences.

What if I have a “bad trip”?

Difficult psychedelic experiences (aka bad trips or spiritual emergencies) are possible during KAP.  The beauty of these types of medicines is that they can amplify what we are experiencing, and in turn help us more deeply connect with what needs healing.  Shifting beliefs and our understanding of ourselves breaks us out of old thought patterns and leads to new insights.  This experience can also feel destabilizing.  This is why therapy is so important.  Trust and feelings of safety within the therapeutic relationship provides the container to lean into these shifts with compassion and curiosity.  Your KAP therapist is very well aware of the possibility of a difficult experience, should it emerge, and prepared to support you.  Hopefully having this information can help you surrender and allow whatever needs to surface as an integral part of your healing journey.

How long do sessions last?

The effects of ketamine typically start 5 to 10 minutes after ketamine dosing. The peak effects typically last 20 to 30 minutes, and then slowly diminish for the next hour. Some alterations in sensory perception, speech, and motor ability may continue for approximately 5 hours. Two to three 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 the administration, and not until all effects have stopped. 

How many sessions do I need?

The current research suggests the best clinical outcomes with at least 3 and the most robust effects from 6 KAP sessions. Together we will determine what works best for you. 

What if I want to continue working with my current therapist?

Trust in your provider enables the deepest possible work to occur. Our providers are trained in KAP and have experience sitting with people in Non-Ordinary States of Consciousness (NOSC) so we recommend working with our therapists in addition to your current therapist. If you have a supportive relationship with a therapist already, there is no need to end that relationship and it can be used in conjunction with your work with us. If your therapist is interested, we may be able to do some joint sessions. 

How much does it cost?

Because it has an “off-label” designation, insurance won’t reimburse for KAP. Many providers don’t want to attempt to get any part of KAP covered due to the concern of not getting reimbursed by insurance companies. Most providers charge $450-500+ for each KAP session. We feel it’s important to make this modality as accessible as possible. Please find out more details about our rates here. 

When will I see the benefits, and how long will they last?

Ketamine treatment can result in a number of benefits, and there are many studies demonstrating its efficacy; however, it is still a relatively new and experimental psychiatric intervention, and there are no guarantees of your outcome. 

Durable 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 other medications and ongoing psychotherapy to reduce the possibility of relapse. Over time, you may also need additional ketamine booster administrations or other therapies to maintain your remission. 

If you do not respond to ketamine after the first administration, repeated treatment will be offered. If you do not respond after a series of 8 dosings, additional ketamine will not be offered. Studies have shown it is not effective to keep treating with ketamine in those who do not respond to the first 8 doses. The treatment team will discuss with you other available options at that time. 

As a byproduct of your experience, you may feel improvement in your emotional state and reduction in symptoms such as depression, anxiety, 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, in the aftermath, 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 these in 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.  This is a unique opportunity for growth and change, and so we encourage you to actively engage in the therapeutic process as well as the medication administration. While medication on its own provides symptom relief, it is most effective in the longterm when combined with therapy and your active participation in the process of integration. 

What are the next steps, or what is the treatment process like?

• Psychiatric eval and approval for KAP

• Preparatory session(s) with therapist (1-3 depending on experience)

• Weekly or biweekly KAP sessions for total of 3 sessions

• Follow up with prescriber to evaluate effectiveness and approval for 3 more sessions

• Weekly or biweekly KAP sessions for 3 more sessions

• Weekly individual integration sessions the day after or two days after KAP

• Weekly group integration sessions

Our treatment team consists of experienced therapists trained in psychedelics and a psychiatric nurse practitioner. If you are in ongoing psychotherapy outside of our clinic, we will be in contact with your therapist and, in some situations, may do joint integration or preparatory sessions with them. 

As a team, we will assess whether KAP is the right intervention for you at this time. We will also collaboratively decide on the most optimal arc for your treatment, including the number and frequency of ketamine and integration sessions, along with dosing suggestions. 

After your initial consultation with one of our therapists, you will meet with the psychiatric nurse practitioner or medical doctor for a clinical intake, during which they will review your medical history, including current and past medical and psychiatric problems, current and recent medications, previous treatments, social history, and history of substance use. They will collect vital signs including blood pressure, pulse, respiratory rate, and oxygen saturation. 

In the preparatory session(s), you will meet with your KAP provider to prepare for your ketamine session, reflect on your goals for treatment, and set intentions for your experience. We may also teach breathing exercises or other mindfulness meditation guidance in this session to address any anxiety you might have going into the experience. The preparatory meetings are meant to build the sense of connection between you and your providers, as we believe that the efficacy of this medication is tremendously enhanced by a safe setting in the context of trusting relationships. 

Can I become addicted?

Ketamine belongs to the same group of chemicals as phencyclidine (Sernyl, PCP, “Angel dust”). 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, since they do not cause tolerance and withdrawal symptoms. However, cravings have been reported by individuals with a history of heavy use of psychedelic drugs. 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 only be used under the direct supervision of a licensed prescriber and in an intentional way such as KAP. We have not had clients become dependent on ketamine. 

What’s the difference between KAP and Spravato (S-Ketamine)? 

Spravato is the result of a pharmaceutical company manipulating the ketamine molecule so that it can be patented. It underwent 3 quick clinical trials in order to get FDA approval a couple years ago. The benefit to Spravato is that since it is FDA approved, it is reimbursable by insurance companies. There are strict protocols in terms of treatment and dosing so the client takes the standard dose and usually sits alone until the effects wear off.  Whereas racemic (generic) ketamine is off-label (so not covered by insurance), it is what is used in KAP. With this model, the prescriber and client can have more freedom in dosing and experience. KAP also adds a therapist or guide sitting with the client throughout the session. Many people talk about Spravato having less hallucinogenic side effects; this is not something that is necessarily avoided in KAP- which is now considered a psychedelic. 

Are there any contraindications (reasons I can’t do ketamine)?

Yes, ketamine does increase blood pressure and heart rate so if there is a concern with that, it might be contraindicated for you to do ketamine. If it is treated and stable then you and the prescriber could discuss that. You would probably need to be cleared by your cardiologist but that would be up to the prescriber to decide.In people with a history of psychosis, ketamine has been known to worsen come psychotic symptoms. We will provide screening questions to see if you have any of these contraindications before moving forward with the intake process.

*Some information on this FAQ was adapted by the Sage Institute which was adapted by the Healing Realms Ketamine Assisted Psychotherapy program