Paradigms of Ketamine Treatment

Raquel Bennett, Psy.D.

Dedicated to ET & FB, who saved my life with ketamine treatment.

Ketamine is a unique and beautiful medicine. It is used all over the world as a surgical and procedural anesthetic. Ketamine was first synthesized in a laboratory in the mid-1960s, and has been FDA-approved in the United States for anesthesia and analgesia since the early 1970s. Recently, an enantiomer of ketamine called esketamine was approved by the FDA for the treatment of refractory depression, which is a game-changer in psychiatry and psychotherapy. Interestingly, ketamine is a highly psychedelic medicine, but not in the classical sense. It is a dis- sociative medicine that quiets sensory input and can launch people into an expansive, transpersonal space.

For many years, ketamine was overlooked as a therapeutic agent because of the bias in Western medicine against psychedelic or psychospiritual experiences. However, in recent years, there has been a resurgence of interest in the therapeutic properties of ketamine as a tool for the treatment of severe and refractory (treatment-resistant) depression, and other psychiatric disorders such as bipolar depression, ruminative suicidal ideation, obsessive-compulsive disorder (OCD), and pain with depression. Clinicians and researchers are also currently investigating ketamine as a possible treatment for post-traumatic stress disorder (PTSD), substance use disorders, anxiety associated with death, anorexia, and chronic relational problems (personality disorders). One of the most interesting questions in the field at this time is whether it is useful and legally defensible to use ketamine as an adjunct for psychotherapy, i.e., for the purpose of spiritual exploration, in the absence of a psychiatric disorder that causes profound functional impairment?

Ketamine is a tiny, chiral molecule that easily passes through the blood-brain barrier. It primarily is a glutamate modulator that acts on the NMDA receptors in the glutamate pathway. There are many different ways to get ketamine into the human body, and each route has a different amount of bioavailability (the amount of medicine that effectively reaches the brain).The neuroscience of ketamine is beyond the scope of this article, and will be covered in a separate publication.

Ketamine is a delicate and flexible tool. There are many different ways of working therapeutically with ketamine. Clinicians and researchers disagree about the optimal way to work with it. One well-known way of working with ketamine is to administer 0.5 mg/kg of ketamine with normal saline solution via intravenous infusion (IV) based on the weight of the patient. The actual infusion typically takes 40 minutes, and the entire appointment takes about two hours. Patients frequently need a series of six infusions clustered together over the course of two or three weeks to induce a robust antidepressant effect using this dosing strategy. This approach to ketamine treatment has been endorsed by the National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA). The new nasal spray containing esketamine will be used in a similar way. It is interesting to note that these protocols were specifically designed not to induce psychedelic experiences in any single treatment session. In this paradigm, the psychedelic properties of ketamine are generally considered to be a problematic (“psychotomimetic”) side effect that needs to be avoided or medicated. This approach to ketamine treatment is fundamentally a Western medical or a surgical model, where the antidepressant or therapeutic effects of ketamine are attributed to its biochemical properties, and the benefits are explained in terms of molecules, receptors, neurotransmitters, and the like. While there is no doubt that ketamine does something helpful on a chemical level, this may not be the whole story. The problem with this paradigm of treatment is that it puts the patient in a passive position; the patient is not called upon to participate in their own treatment (except to show up for the appointment), and all of the “magic” is attributed to the chemical action of the medication.

A different way of working with ketamine is to use it as a lubricant in the psychotherapy process. The basic idea here is to offer the ketamine session(s) in the context of an ongoing psychotherapy relationship, in order to help the patient talk about material that is too painful or shameful to discuss otherwise. In this approach to ketamine treatment, the medicine is typically administered via a lozenge (transbuccal and/or sublingual ab- sorption) or intramuscular injection (IM) in the 0.3–0.8 mg/kg range, and the session takes 1.5–3 hours, depending on the dose. (Note that you have to know the bioavailability of each route of administration to do the calculation correctly). Often, what we see clinically is the “consolidation” of psychological material. This is not the time to go searching for new memories. Instead, patients convey that their understanding or resolution of a difficult issue moves from being intellectualized into an embodied way of knowing. This way of working with ketamine fits into a psychological and relational paradigm, where the beneficial effects of ketamine treatment are attributed to the metabolism of psychological material, and the emphasis is on the psycho- therapy process. Note that this kind of work can only truly be done by a trained psychotherapist embedded within the context of regular talk therapy sessions (which is conceptually similar to the MDMA-assisted psychotherapy protocol for treating PTSD); any other kind of provider in any other context is of- fering pseudo-therapy.

Another way of working with therapeutic ketamine is to use it to purposefully induce mystical and psychedelic experiences. Patients must be carefully selected and prepared for this kind of experience, as it can get very weird or be frightening in the absence of adequate preparation. To induce a psychedelic ketamine journey, 1.0–2.0 mg/kg of ketamine is administered by intramuscular injection (IM) by a medical professional in a safe and supervised environment. This typically causes the patient to temporarily enter into a state of conscious sedation or a special level of altered consciousness that precedes full anesthesia, and may include temporary partial paralysis. Patients report having vivid dream-like visions during the active medicine phase, which can begin a few minutes post-injection, and which may last approximately 75 minutes on average (depending on the dose), followed by several more hours of sedated recovery. Patients often have the experience of being “dissolved” as they enter into the dissociative and transpersonal space, and it is not uncommon for patients to report that they were in communication with a “divine energy” or “being” during their disembodied travels. When clinicians choose to work in this way, they are working in a psychedelic and shamanic paradigm, in which the mystical visions are valued. (Note that in the previous two paradigms, the mystical visions are avoided.) The role of the clinician is to ensure the physical and psychological safety of the traveler, and then later, to help the patient construct meaning from their visions and identify the action(s) that the patient can take to move toward wellness.

So which of these treatment paradigms works the best? In other words, what is the “right” way to use ketamine therapeutically? The answer is that all of the paradigms are useful. In my 17 years of experience to date, it is clear that different things work well for different people: Some patients are excellent candidates for a series of low-dose ketamine infusions or nasal spray; some patients are tied up in emotional knots on the inside and truly

benefit from ketamine-facilitated psychotherapy; and a tiny fraction of clinical patients are actually good candidates for a full psychedelic ketamine journey. Learning how to distinguish which patients are likely to benefit from each strategy is beyond the scope of this article and the subject of much active debate in the clinical ketamine community. My goal is to educate patients about the variety of therapeutic ketamine services that are available, and to educate providers about how to work with various routes of administration and different dosing strategies for ketamine. Also, in reality, the different ways of thinking about ketamine treatment actually overlap and blend together. For example, when we offer a psychedelic ketamine journey to a patient, we are attentive to the therapeutic relationship, we are interested in the content of the visions, and of course the ketamine is affecting the brain on a chemical level, all at the same time.

Because of its importance in medical and surgical settings, ketamine is uniquely positioned as a highly hallucinogenic agent which is legal to prescribe and administer. Ketamine offers us the valuable opportunity to study psychedelic, transpersonal, and dissociative experiences without all of the bureaucratic red tape associated with studying other Sacred medicines. I think we are currently under-utilizing ketamine as a research tool for expanded mental states, mood modulation, and the possible connection between them. However, the easy access to ketamine creates another clinical dilemma, namely that ketamine in the transpersonal dose range is a terrible place to begin psychedelic exploration, because the dissociative experience can be so strange. What does adequate preparation look like? Also, is it psychologically safe for patients to do this kind of exploration on their own? These questions are actively being discussed within the clinical ketamine community.

Ultimately, the availability of therapeutic ketamine invites us to return to several essential questions. Is there any value in having psychedelic experience (in a contained medical environment)? I think that there is. Some people report that their psychedelic ketamine journeys were some of the most meaningful and educational experiences of their entire lives, while psychedelic ketamine experience would be extremely inappropriate for other people. Are the visions an annoying side effect, or are they a beneficial (or essential) component of the treatment? Finally, what are the implications for the broader field of medicine if we embrace the psychedelic component of ketamine treatment, instead of turning away from it?

Raquel Bennett, Psy.D. is a psychologist and ketamine specialist from Berkeley, CA. She has been studying the therapeutic properties of ketamine since 2002. Dr. Bennett is the founder of KRIYA Institute (kriyainstitute.com) and the organizer of KRIYA Conference, which is an annual and international event devoted to the use of ketamine in psychiatry and psychotherapy. Dr. Bennett has a long- standing interest in the relationship between mood modulation and psychedelic experience.

Appointment Request

1
Contact
2
Preferences
3
Choose A Clinician
4
Availability
First Name *
Last Name *
Email *
Cell Phone *
Client's Age *
Resident State *
Preferred Method of Contact *
Have you had KAP therapy before? *
Are you comfortable with us leaving a message identifying us? *
Who referred you to us? *
Tell us what brings you to The Ko-Op.
Choose A Clinician Or Click Next To Skip
Jennifer O’Donnell

Jennifer O’Donnell

M.A., Counseling Psychology, Certified Psychedelic Facilitator through Soundmind in Phila.

Jennifer is an experienced mindfulness-based psychotherapist. She holds
a Master’s degree from Delaware Valley University in Counseling
Psychology, and a Bachelor of Arts degree in Political Science from
Temple University. Jennifer is a certified sexual assault counselor, an
experienced certified yoga therapist, and a certified yoga and Pilates
instructor. Jennifer has completed post graduate training with
Soundmind Institute in Philadelphia as a certified Psychedelic
Facilitator. She offers an array of therapeutic techniques which include:
Trauma Focused – Cognitive Behavioral Therapy (TF-CBT), Dialectical
Behavior Therapy (DBT), Mindfulness Based Stress Reduction
strategies and trauma informed yoga therapy. Jennifer’s therapeutic
approach encompasses the integration of therapy, yoga, breath work and
mindfulness and includes a blend of therapeutic modalities such as
somatic experiencing, attachment theory, psychodynamic, and Hakomi.

“ I see counseling as a safe and therapeutic relationship. My approach
is a blend of both clinical and alternative therapies designed to meet the
needs of each individual. The goal is for you to gain insight and clarity
into your thoughts and feelings in a supportive and encouraging
relationship as we uncover new paths to your personal healing and
transformation. I believe we all carry inner wisdom, and when we start
quieting our minds and listening to our bodies the wisdom can then be
heard.”
Jennifer has experience in treating trauma, PTSD, anxiety, depression, bipolar
disorder, obsessive compulsive disorder, women’s issues, family
conflict, sexual and gender identity issues, grief, behavioral issues and
life transitions. Jennifer has a deep understanding of how trauma shows
up in the body, and continues her personal practices to deepen her own
understanding of self, consciousness, and collective healing.

Sophia Polin

Sophia Polin

MASTER OF SCIENCE MS: MENTAL HEALTH COUNSELING

I am an integrative therapist whose practice combines relational theory with elements of Cognitive Behavioral Therapy. In my standard practice I work with adults and adolescents with histories of trauma, who are facing major life transitions, struggling with anxiety and depression, who are dealing with relationship discord, or who want to explore their full potential. I have substantial experience working with Post-Traumatic Stress Disorder as well as Obsessive Compulsive Disorder. I practice Exposure and Response Prevention (E/RP) for OCD, and take expert care in helping my clients face and overcome what they fear most.

In session, I emphasize attuning to the mind-body connection, habituating to feelings of vulnerability, and integrating disparate “parts” of the psyche in order to guide clients towards conscious, intentional lives and relationships. I consider early life and relationships to be integral in the formation of the personality and of patterns of behavior later in life.

I have recently expanded my practice to include psychedelic therapy. The use of psychedelics in a therapeutic setting gives clients the unique opportunity to distance from ingrained ways of thinking, connect with their own healing intuition, and dissolve the boundaries of self that are no longer serving them. The transformative shifts we are seeing in Ketamine treatments are the result of— the creation and reorganization of pathways in the brain (neurogenesis and neuroplasticity). These are the same processes therapists have been using traditionally to support their client’s growth and healing. I like to think of it as automating what has traditionally only been achievable manually.

Occupying altered states can be scary at first. My role as a psychedelic therapist is to lay the grounds for a safe and revelatory journey. In our preparation sessions we will build essential trust, explore your history, and collaboratively set your intention for your psychedelic experience. We will use our integration sessions post- treatments to synthesize and apply the wisdom gleaned from your journey to affect lasting, meaningful change. Whether you are experienced with psychedelics or exploring psychedelia for the first time, I am with you every step of the way.

Jeffrey Shralow

Jeffrey Shralow

Not available for booking
Support Staff
HARM REDUCTION SPECIALIST
MSN, CRNP, PMHNP-BC, MA

I am a licensed and certified Psychiatric Mental-Health Nurse Practitioner, with a M.S.N. from University of Pennsylvania.  I have a Master of Arts in Buddhist Studies from The Naropa University.  My clinical work is integrative and holistic, with a harm reduction ethical framework. I am trauma-informed and person-centered; these are the foundations for my practice.  I am committed to informed decision making as well as providing clear and understandable educated answers to any question that might arise.  I am committed to the highest levels of professionalism and to ensuring a safe and therapeutic experience.  I am trained and experienced in providing psychedelic integration therapy and Ketamine Assisted Psychotherapy (KAP).  I consider access and inclusion within diverse populations and expressions of the highest priority.

I have been studying and practicing healing and growth processes within the intersection of psychiatry, neuroscience, trauma theory, psychology, and spirituality for several decades.  I have focused on actualizing treatment approaches at the cutting edge of the rapidly expanding and evolving paradigms within psychiatry and consciousness studies. I am particularly excited to be expanding into the field of psychedelic-assisted therapies

My clinical work includes psychotherapy, coaching, and education within a wellness orientation.  Therapeutic specialties include mood dysregulation, anxiety, trauma, psychiatric symptom management, spiritual emergencies, global climate crisis related dysregulation, as well as insight and growth aspirations and psychedelic integration. Integrative elements of psychodynamic/Jungian/Gestalt and transpersonal psychologies, eco-psychology, Buddhist psychology and the mindfulness sciences, as well as Eastern/Asian medicine theory and energy psychology are the foundations of my clinical work.

Stephanie Josephson

Stephanie Josephson

LCSW

I am a Licensed Clinical Social Worker with 20+ years of experience working with people in Philadelphia, New York City and San Francisco.  I am certified in Psychedelic Assisted Therapy and practicing Ketamine Assisted Psychotherapy at the Ko-op.  My client may be a person who currently feels stuck in their life, dealing with chronic health issues, issues related to being queer, trans or non-binary,  concerns about use or mis-use of substances, or dealing with depression or anxiety.  My focus is to work collaboratively with clients to foster growth and personal development in a supportive, judgement-free environment. We can develop skills to deal more effectively with overwhelming feelings, identify your strengths, and work together to overcome challenges in your life.
Psychedelic Assisted PsychoTherapy is a tool to help feel unstuck, expand your perspective and deal with events in your life that, in the past, you have been unable to fully address.  I offer Preparation sessions where we build rapport, gain an understanding of what to expect during a medicine session, and set intentions for what you would like to achieve. I also offer Integration Sessions, weaving the insights gained during your psychedelic journey into your conscious living.
I look forward to speaking with you, and discussing how we can work interactively so that you can better navigate your way forward
Megan Remsen

Megan Remsen

Licensed Social Worker (LSW)

I am a psychodynamic therapist trained in the analytic tradition with specialization in integrated trauma treatment. My practice is grounded in using psychedelic psychotherapy to promote relational and internal acceptance and stimulate growth in spaces that previously seemed stagnant. My kaleidoscopic background and diverse trainings in social work, anthropology, native plant medicine and community healing support my practice. I value and feel curious about the use of dreams, mythology, and intangible heritage as insights into our construction of Self. I embrace the use of non-ordinary states to support the work of engaging with these inner realms.

Psychedelic journeying provides expansive opportunities to engage with and feel curious about the events and beliefs that have shaped our experiences. Our sessions will prioritize interpreting and integrating the insights from your journey into your conscious experience, in support of your relationship with new ways of being. The elasticity of journeying benefits from a secure and stable holding relationship, I will provide collaboration and witnessing through every step, and I recognize and will respond to the vulnerabilities of these new states.

Much of my work centers on supporting the effects of transitions and change on the mind, spirit and body. In our sessions, we will examine the systems, early childhood experiences and deeply internalized messaging that continues to constrain the expansiveness of who we are. Together, we will move towards illuminating those spaces and undoing their harm.

I recognize the oppressive impact of contemporary conditions on the human experience, and I strive to hold the complexity of the treatment I offer and meet clients where they are. I collaborate on a course of treatment that fosters a sense of physiological, emotional, and relational security, while addressing economic realities. I offer a sliding scale and I am happy to consult on a course of treatment to meet unique needs. I center social justice in my work, welcome all sexual and gender identities and make an LGBTQ+ affirming space a priority. Whether you are new to Ketamine Assisted Psychotherapy or returning to continue your insights, I offer a constructive space to work through the subconscious to foster connectedness and curiosity in support of relief from severe depression, attachment injuries, PTSD and anxiety.

Dr. Sophia Brandstetter

Dr. Sophia Brandstetter

LCSW, PSYD CLINICAL DIRECTOR

I am a licensed psychotherapist who is rooted in psychoanalysis and psychodynamic and relational theories. In recent years, as a compliment to my psychotherapeutic approaches, I’ve shifted my training to include psychedelic medicines as a method for integrating the mind, body, and soul. In many ways we are rediscovering verifiable facts about the impact of psychedelic medicines on our neurochemistry, physiology, and psychology. I have witnessed plant medicine as a power catalyst for change for my patients.

At this time our work must center around Ketamine Assisted Psychotherapy. Ketamine is renowned for uncovering our intrinsic healing capacity while transporting us to a place of higher consciousness. The ketamine psychotherapy experience can bring attention to deep-rooted emotions, patterns, narratives, and/or experiences that could be unconscious sticking points or barriers to our growth. Ketamine sessions often access an abundance of material that might take months or years to uncover in traditional psychotherapy. Previous patients have stated, I have felt in a couple of hours, I have learned more about myself than I have in several years of psychoanalysis. Confirmations like this are common and the insight the ketamine sessions impart can remain long after the effects of the ketamine have dissipated.

At higher dosages, psychedelic medicines have the capacity to allow for significant disruptions of self‑consciousness, a phenomenon known as medicine-induced ego dissolution. Using your experience with the medicine as a guide, we can collaborate in understanding the experience of dissolution to create opportunities for regeneration and integration.

As you can see, I believe providing therapeutic support to be a vital part of the curative mechanism of the psychedelic experience. Together we will work on building a therapeutic relationship founded on trust, safety, and mutual respect for the sacred work the medicine can help facilitate. The approach we co-create can enhance the experience and make way for relief and change.

If you’re entering treatment to address trauma or if you’ve experienced trauma, it’s important to understand the healing significance of the therapist as a witness. Research on treating trauma explores how the witnessing (experiencing the presence of another) is considered an essential prerequisite for our capacity to narrate our experiences. One of the crucial impacts of a trauma is the damaging effect caused by the absence of a witness: without a witness we may have lost touch with how to make sense of what has happened, but when we gain a witness, the experience becomes more possible to know and understand, and healing can begin. As your witness in your psychedelic journey my role is to be visible in all the necessary ways to offer support.

My intention is to design a program that meets your expectations. I’m open to the many possibilities of what may work for you and want to invite you to imagine and share your hopes and needs for the journey. A psychedelic experience is a personal process and I welcome the opportunity to meet for a free consultation to answer all your questions and provide you with a comprehensive understanding of the possibilities

No Preference

No Preference

None

Daily Availability *
Time Availability *