Episode 246: Understanding the Process of Ketamine-Assisted Psychotherapy

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 Dr. Melissa Smith 0:00
What happens during ketamine assisted psychotherapy? How does it work? How does it address mental health concerns? Join me as I do a deep dive into the process of ketamine assisted psychotherapy.

Dr. Melissa Smith 0:12
Hi, I’m Dr. Melissa Smith. Welcome to the Pursue What Matters podcast where we focus on what it takes to thrive in love and work. Well, hopefully you joined me last week as I introduced you to ketamine assisted psychotherapy, it is a breakthrough. treatment for mental health concerns, personal transformation, and it’s kind of taking the world of psychiatry by storm. So if you haven’t listened to last week’s podcast, and you’re interested in this topic, I would jump back and listen to that one first, where I introduce ketamine assisted psychotherapy. And today we’re going to jump into the nuts and bolts of treatment. What happens? What does it look like? What does it feel like? How does it work?

Dr. Melissa Smith 1:13
So we’re going to talk about the safety profile of this treatment, routes of administration and the experience of the medication on the brain. So I hope you’re ready to learn all about ketamine assisted psychotherapy. And of course, every week with the podcast, my goal is to help you strengthen your confidence to lead by helping you lead with clarity, which is all about connection to purpose and meaning, leading with curiosity, which is all about self awareness and self leadership, which we’re really focusing on today, and leading and building a community. And so let’s jump right in and start with this first question, which is how is ketamine assisted psychotherapy used in mental health treatment? So in general, there are three accepted uses of ketamine in psychiatry. The first is ketamine assisted psychotherapy, and this is with a psychedelic focus. So this often includes intramuscular, or intravenous dosing experiences with ketamine and include brief therapy before and after dosing, sometimes in the middle of dosing and psychotherapeutic integration sessions in between dosing sessions. So that is what many people think of when they think about ketamine assisted psychotherapy, it is a psychedelic experience, which is inward focused, and does include some therapy before towards the end of dosing, and then in between sessions.

Dr. Melissa Smith 2:47
The second main approach is psycholytic, ketamine assisted psychotherapy. So when we think about psycholytic dosing, we think most often of oral or nasal routes of administration, so lozenges or turkeys are oral, and then we have nasal sprays, often known as spravato, which is an FDA approved spray for the treatment of depression and other mental health disorders. And this is, the medication is taken at the beginning of a dosing session to facilitate openness and deeper therapeutic work with a therapist present for the entire session. So this is where you’re actively doing therapy with the assistance of the medication as a lozenge or a nasal spray. And then we have the psychiatric ketamine, or most typically spravato. This really is a medical intervention, which includes the use of that nasal spray spravato. It’s a prescription medication, and FDA approved for depression. This treatment solely focuses on a decrease of depressive symptoms, and does not typically include a therapeutic component.

Dr. Melissa Smith 4:04
Now, last week, I talked about, you know, differences between treatments, and there are a lot of ketamine treatments where they just include maybe the nasal spray, or they’re just including IVs, or even I am, but there’s no, there’s no psychotherapeutic component, meaning there’s not a focus on integration. And there’s it’s really just a medical intervention, where people go to the doctor, they get ketamine infusion, and then they leave. And so this would be that third component that psychiatric ketamine, so it’s a medical intervention. And what I would say is with that intervention, you’re leaving a lot on the table, you’re leaving a lot of opportunity for therapeutic benefit, when you don’t include the therapy integration as as part of ketamine assisted psychotherapy. But it’s import And to know that those are the main ways that ketamine is used in mental health treatment. So the next question, we’ve addressed this just a little bit, but let’s say a little bit more. How is ketamine therapy administered? So the route of administration or ROA is based on diagnosis presenting concerns, treatment goals and medical status. And the common routes of administration include intramuscular, or I am intravenous or IV, oral, which would be a lozenge or chokyi, or nasal, which is typically the spravato spray, which is FDA approved. And so when we think about ketamine assisted psychotherapy, we can use all forms of those routes of administration.

Dr. Melissa Smith 5:43
For ketamine assisted psychotherapy, it really depends on the presenting concerns. It depends on comfort level, anxiety. So sometimes if you have someone who’s really anxious, you might start with an oral administration to help people to kind of get a feel for the medication before they have a deeper experience. And that can be really helpful. So specifically, what is ketamine intramuscular therapy. So this includes a subcutaneous shot in the upper deltoid. So in the upper arm, given by a qualified medical provider, always we have, you got to have good medical supervision. Additional doses can be administered depending on the needs and indications of the individual. And then integration therapy includes psychotherapeutic interventions before during, after an in between dosing sessions. So we’re doing some KAP today. So earlier today, I did some therapy with a with a client before they were dosed. And then they were dosed, and we gave them about 4045 minutes to really have an internal experience. And as they were starting to wake up and come to a little bit, we stepped in and we did some additional therapy. This is such a powerful window of opportunity, where you’re really helping to helping people to extend their dosing experience, to, to really garner meaning, and to have a body based experience of healing. It’s incredible. It’s so remarkable every time that happens. And then for for these clients, we will also often have integration sessions between dosing sessions to really help them to pull together what’s happening for them, what are the changes, what does it mean for them in their life. And so when it comes to im dosing sessions, medical management includes medical checks and vitals to proceed to dosing, continuous vitals throughout dosing, medication administration and ongoing oversight by medical provider. And the IM dosing therapeutic management includes helping clients to manage expectations, PACE breathing, which is very important meditation setting an intention, ensuring a therapeutic setting, and ongoing oversight by support and therapy, staff and then of course, some psychotherapeutic interventions.

Dr. Melissa Smith 8:15
So next, let’s move to intravenous infusion therapy. So when we think about IV IV infusion with ketamine assisted psychotherapy, right like this is this is what we really need to pay attention to. It includes an IV infusion over approximately 40 minutes conducted by a qualified medical provider integration therapy includes psychotherapeutic interventions before after, and sometimes durian towards the end of a dosing session. And then, of course, all the same medical management and, and therapeutic management during those dosing sessions. Sometimes we will use IV dosing for someone who has some medical concerns, or we just want to keep a much closer eye on it because with IV, you can really do that well. And that provides continuous medical monitoring, which is great. I also just want to highlight again, all of this is just educational. We have medical providers that do all of this. So I’m a licensed psychologist, I am not a medical provider. I don’t do any of the medical component, which is part of why you want to have a strong comprehensive, multidisciplinary treatment team, because we need all of those providers active and participating as part of KAP.

Dr. Melissa Smith 9:35
So next one is ketamine oral therapy or with lozenges or chokyi. So this is this is where an individual has a prescription for the ketamine and they bring their lozenges to session, and they dose themselves at the beginning of a therapy session with their therapist, the therapist is there the entire time, and this oral administration is can siddur psycholytic which facilitates emotional expression and an ability to access deeper therapeutic work. So during these oral sessions, clients are able to engage in therapeutic discussion with the therapist. And then you can also do integration therapy sessions in between dosing sessions to help solidify connections. Of course, before the oral dosing sessions, a full medical intake has been done to make sure that they’re appropriate. And then finally, what is ketamine nasal therapy or spravato? So spravato is an FDA approved ketamine nasal spray for depression. It is not typically considered ketamine assisted psychotherapy, because it’s typically just the medical component of the spray but not a therapeutic intervention. There may be exceptions, it depends on how clinics are using it, but it’s under pretty tight regulations with how spravato is used. So the next question that often comes up when we think about ketamine assisted psychotherapy is how safe is it?

Dr. Melissa Smith 11:09
So ketamine, the medication has been widely used in medicine for anesthesia and pain for decades. But its potential to facilitate significant symptom reduction in a host of mental health concerns, represents a really new shift in the field of psychiatry. So, ketamine is a synthetic pharmaceutical compound classified as a dissociative anesthetic. It’s one of the most widely used medications in modern medicine, and is on the World Health Organization’s list of essential medicines. So it was first developed in 1963. FDA approved in 1970, and adopted by many hospitals and medical clinics because of its rapid onset, proven safety and short duration of action. So ketamine is commonly used in surgical settings, including pediatric surgery due to its excellent safety profile, particularly around breathing and airway management. It’s also used just about every day in emergency departments. It has also been utilized successfully in managing acute and chronic pain conditions due to its analgesic properties.

Dr. Melissa Smith 12:16
So in the past two decades, ketamine has been increasingly clinically applied to sub anesthetic doses as an off label treatment for various chronic treatment resistant mental health conditions, such as depression, alcoholism, anxiety, dependency, substance dependencies, post traumatic stress disorder, OCD, eating disorders, and other psychiatric diagnoses. So, if you are considering ketamine assisted psychotherapy, you must work with licensed medical providers who who have excellent ketamine assisted psychotherapy training for the non aesthetic, non aesthetic use of ketamine. So, you know, your medical provider should all have the relevant current advanced life support cert certification, medical providers on site and available to recognize and treat airway complications to rescue a patient who enters a deeper than intended level of sedation, sedation, and have full access to advanced cardiac life support crash carts, treatment rooms, or pre staged with airway adjuncts, and you have everything that you need to go. Now the thing is, we want to provide ketamine assisted psychotherapy in a therapeutic environment, sometimes if it’s a heavy medical setting, that can really undermine that the setting component of, of KAP, and yet you must have all of that medical access immediately available to you. And so it’s really important to pay attention to making sure you have everything that you need, and also making sure that it’s a therapeutic environment for individuals.

Dr. Melissa Smith 14:10
So the next question is, what kind of medical monitoring is included during ketamine assisted psychotherapy, so prior to receiving medication, medical providers, assess vitals, inform patient of the level of sedation, the dosing, the description of the medical monitoring so that patients are involved every step of the way, and then ongoing vitals throughout dosing. So you always have line of sight and medical monitoring on board. So what should you expect from ketamine assisted psychotherapy? So with many KAP treatments, including ours, there are often three treatment components components, first assessment and preparation second, ketamine dosing, and third integration. So as part of assessment and preparation, you complete medical intake with a medical provider and a psychiatric intake with psychiatric specialist. So a mental health therapist, these comprehensive assessments help determine that KAP is an appropriate treatment for you. So if you are looking at a place for treatment, and they don’t have a thorough assessment, be warned, that should be a red flag. The second stage or second component of KAP is ketamine dosing. And so it’s typical you you would probably complete approximately six ketamine dosing sessions with a medical provider and therapist ideally scheduled during a three to eight week window based on diagnosis presenting concerns and treatment goals. Now, the pace and the rate of these dosing sessions is highly specific to your presenting concerns or symptom management. And then you also the dosing the route of administration is also determined based on your needs, it’s totally fine to do a hybrid approach where maybe you would start with oral and then move to I am or introduce oral as something that can be very helpful for some of those integration sessions or the sometimes an exploration session with a psycholytic dose. And so that is a really important part of, of developing a treatment protocol is it’s, it’s highly specific to the individual.

Dr. Melissa Smith 16:37
And then the third component is KAP integration. So integration therapy sessions are done as part of dosing appointments. And also in between dosing appointments. This is such a powerful treatment. And I would say probably there are the majority of people who do ketamine therapy, do not do therapy, during dosing, but it is really powerful. And you know, it’s something that you need to be trained for, you need to have specialized training for. But when you see this, you know, really skilled clinicians engaging in therapy during dosing sessions, it’s really incredible to see. And so with integration, you typically we’ll have, you know, six to eight, integration sessions, those are closely tied to the dosing appointments. Because you’ve got that that window of opportunity is open, where you get more, you can really leverage the positive effects of the medicine. And so that’s what integration really looks at integration also is very focused on helping individuals gain traction on building good habits that support well being and serve as protective factors against relapse or worsening symptoms. And so here at our clinic, we are really big on coping skills, mindfulness practice, prioritizing self care activities every single day, to really make the changes sustainable. And that’s really where people find the greatest effectiveness is they get more traction on coping skills. And that’s great because that’s something you can enlist every in every moment of your life. And then at the end of ketamine treatment, we we move into a maintenance stage, and that is based on symptoms.

Dr. Melissa Smith 18:35
So some people need another dosing session maybe a few weeks or several months afterwards. But it’s highly dependent and we just, we keep a close eye on symptoms, and work closely with individuals to determine when or if they might need a booster dosing appointment.

Dr. Melissa Smith 18:58
So what does I’m going to answer ask a couple more questions to really help you get a feel for this treatment. So what does ketamine therapy feel like? So, as mentioned, ketamine assisted psychotherapy is very effective in addressing a variety of presenting concerns. It is often experienced as a dreamlike state that may include an out of body experience that is not uncommon with the psychedelic focus. So during dosing individuals may experience a sensation of surrender a feeling of formlessness, where they have separation from their body interconnectedness, it’s not uncommon to feel a great deal of love, a sense of humility, or gratitude, and union with spirituality or higher power.

Dr. Melissa Smith 19:48
So ketamine increases access to experiences outside of conventional time and space. And it really assists individuals in navigating the range of ecstatic to challenge and experiences during dosing, and you really can have the full range. And all of those experiences along the whole continuum can be therapeutic and can be beneficial. This is one of the reasons the therapeutic intervention is so important because it helps people to get all of the benefit from those experiences. And we’re not just labeling experiences as good or bad or negative or positive, but we recognize that each experience has deep meaning and value and opportunity for growth and learning. Ketamine also provides dose related flexibility based on the therapeutic goals. So again, you can have the psychologic processing to the psychedelic transpersonal experience. So there’s also a range of that focus. So when it comes to ketamine dosing, the reduction of external stimuli heightens the internal visual experience. So we like to have people where imass Listen to music. This allows connection to the symbolic realm of experience. Ketamine is really great for preserving the observer. So being a witness to your experience, not a judge of your experience, the part of the self that’s able to witness consciousness with non attachment and non judgment. And so with ketamine assisted psychotherapy, it includes a reduction in negative, obsessive and self referential thinking, and facilitates a spaciousness of mind, a freedom of mind and a sense of movement in goal directed paths. So it can be really incredible in that way.

Dr. Melissa Smith 21:40
So as mentioned, so this question How many sessions are typical with ketamine therapy, I mentioned this, that the length of ketamine assisted psychotherapy varies greatly. Your treatment should be tailored to your specific needs, including presenting concerns severity and duration of symptoms, responsiveness and previous treatments. Typically, though, we’re looking at about six dosing sessions and about six integration sessions during a three to eight week period. And that seems to be very helpful for a majority of individuals. And then the last question we’ll look at is what happens after you complete ketamine therapy. And so at the conclusion of treatment, we will, you know, our team and any team you should be looking at should continue to closely monitor your symptoms to assess if or when maintenance KAP may be indicated. So our team uses valid and reliable assessments, in addition to clinical observations, and client self report, if you don’t have a team that is assessing you globally, you know, you might want to double thing, or you might want to think twice about whether you move forward with them. So it’s not uncommon for individuals to benefit from maintenance KAP anywhere from one to six months post treatment, and that’s the comprehensive treatment and maintenance KAP may include one to two dosing sessions with integration based on the significance of symptoms. And so it’s really important to stay in touch with your KAP team, so that you can work together to monitor those symptoms and make sure that you’re getting the benefit and getting back in so you can get that booster dose to help you.

Dr. Melissa Smith 23:27
So head on over to my website to check out the show notes with all the great resources for this episode at www.drmelissasmith.com/246-processofketaminetherapy. So that’s a long one. Once again, www.drmelissasmith.com/246-processofketaminetherapy. Again, all of this is for informational purposes only it should not be construed as treatment or medical advice, or therapeutic advice. But the hope is that this can give you some good information. It can be a good resource as you as you consider options for yourself or for your loved ones. I will link to our clinical website and also our KAP website so you can gain more information there, if that could be helpful. In the meantime, I’m Dr. Melissa Smith. Remember love and work, work and love. That’s all there is. Until next time, take good care

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