Ketamine Therapy Treatment: Who, What, and How?
Ketamine, an anesthetic developed in the 1960s and still used everyday in hospitals all over is now the only legal prescribable psychedelic drug. Ketamine treatment is having profound healing effects in people suffering from depression, anxiety, and PTSD by offering a psycho-spiritual experience in which a person is temporarily relieved from the depressed/anxious default modes of thinking and feeling. Instead, a person may have an objective and introspective view of their suffering instead of being consumed by it. As the novel treatment gains awareness for its successes in reducing mental health issues, the efficacy of the treatment can be explored when considering who can administer the drug, facilitate a therapy process, and how that is being conducted.
Who is able to facilitate ketamine treatment?
Currently there are no credential requirements for who can offer ketamine treatment, and yet there is a wide range of mental health and medical professionals who are thereby able to facilitate the process. These include nurse practitioners, doctors, psychiatrists, psychotherapists, guides and even “ketamine coaches.”
While only doctors and nurses are able to administer the drug through intramuscular or intravenous methods, any other provider (therapist, coach, nurse) who is in collaboration with a medical “prescriber” can stand by while the client self-administers a lozenge or nasal spray form of the drug that has previously been prescribed to the client by a doctor or psychiatrist and filled at a pharmacy. In using the lozenge and nasal spray forms of the drug, a client does not need to be in a medical office and can take the medicine in a session with their therapist, at their therapist’s office, or when allowed, in the comfort of their own home while being in a video session with their therapist.
With respect to the ever demanding need for increased access to mental healthcare, the wide range of practitioners that can currently offer ketamine treatment means that patient/client access to the ketamine treatment increases. It also means that providers who are not clinically trained as licensed mental healthcare professionals are able to administer a powerful psychologically-altering psychedelic drug without the presence of a licensed therapist to facilitate the “therapy” part of the process.
While some doctors or nurses may decide on their own accord to take courses or certificates from some of the ketamine therapy training programs, this is a drop in the bucket in comparison to the three years of graduate school and 3,000 client hours that licensed therapists are required to complete in order to meet the requirements for their governing boards.
In comparing the education and experience of a licensed mental health professional and a licensed medical provider, we can ask the question, what makes for a “successful” outcome of ketamine treatment–wherein mental health symptoms have been relieved and/or have sustained remission. And to talk about the successful outcomes we need to first define “Trauma with a capital “T” and “trauma with a lowercase “t.”
Depression/anxiety as a symptom of trauma
For the majority of people, when they hear the word “trauma” they think about a PTSD diagnosis and a tragic event in a person’s life that can cause severe mental health symptoms including suicidality. Things like sexual assault, car accident, or being involved in a war zone may all be associated with (an) event/events in a person’s life that were so overwhelmingly life threatening that they created intense and lasting emotional anguish. Some mental health professionals call these types of traumas “trauma with a big T” or “big T trauma.”
Another type of trauma that a person may experience is what some call “trauma with a little t.” These types of trauma are “relational trauma,” “attachment trauma,” “developmental trauma,” or “complex trauma” (C-PTSD).
Attachment trauma refers to the emotional and mental impact of a relationship, usually between a child’s main attachment figures or caregivers, where the child’s needs for love, care, affection, attention and safety were consistently unmet and because of this, as adults they have formed mal-adaptive beliefs, behaviors, views of self/others/the world, that keep them stuck in a depressed/anxious cycle.
Developmental trauma is also under the umbrella of “little t trauma,” and can include experiences in a person’s development that had a negative impact on their social and emotional growth such as bullying, learning disabilities, immigration, poverty, stigma around sexual orientation or gender presentation, racism, or violence in the home. Complex trauma is a term that includes relational, attachment, or developmental trauma that is persistent throughout a person’s early development.
What causes “little t trauma?”
The term ACE (Adverse Childhood Experience) was coined as part of a massive (17,000 participants) study which was conducted by the Center for Disease Control and Kaiser Permanente. Researchers found that there are 10 ACEs of trauma that impact the vast majority of sufferers. People who have experienced more than one of these issues may struggle with developmental trauma, or complex trauma. They are also at higher risk for increased rates of both mental and physical illness.
The 10 ACEs of trauma are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. They include physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, divorce, substance abuse, domestic violence, mental illness, and having a relative who has been sent to jail or prison.
According the Center for Disease Control and Prevention (CDC) website,
“ACEs are linked to chronic health problems, mental illness, and substance use problems in adulthood. ACEs can also negatively impact education, job opportunities, and earning potential. These experiences can increase the risks of injury, sexually transmitted infections, maternal and child health problems (including teen pregnancy, pregnancy complications, and fetal death), involvement in sex trafficking, and a wide range of chronic diseases and leading causes of death such as cancer, diabetes, heart disease, and suicide.
ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, frequently moving, and experiencing food insecurity, can cause toxic stress (extended or prolonged stress). Toxic stress from ACEs can change brain development and affect such things as attention, decision-making, learning, and response to stress. Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. These effects can also be passed on to their own children. Some children may face further exposure to toxic stress from historical and ongoing traumas due to systemic racism or the impacts of poverty resulting from limited educational and economic opportunities.
What seems overwhelmingly true for the clients that have sought out ketamine therapy with me in my private practice model, is that these are adults with long withstanding depression and anxiety who can all identify developmental and/or attachment trauma from their past. What this means is that for these symptoms to not only be lifted, but sustained, that the very traumas that caused these must be addressed and be given healing opportunities. What this also means is that “ketamine treatment” that consists of just the medicine ketamine itself without any talk therapy, is likely not sufficient to heal and sustain mental health. Instead we must consider that a licensed, trauma-trained psychotherapist with years of experience working with clients, who has the training and the skills to attend to the attachment wounds of the inner child, are an integral part of successful ketamine therapy treatment.
What does the “inner child” have to do with my anxiety and depression?
As children, the adults that surround us and the environment we are within, all shape the way we learn to adapt to distress and survive. Because as children we cannot exercise the same survival choice that we have as adults (fight/flight), the child must learn how to adapt to environmental circumstances in order to survive and continue to be fed and housed by their parents. While an adult who is being mistreated at a job site can decide to leave (flight response), a child who is being emotionally or physically abused cannot fight the stronger adult, as it does not have the physical strength, or leave the home, as they do not have the tools to survive on their own.
When the healthy fight or flight stress response is not able to be used, a child or person will go into another autonomic state in the nervous system which is not fight or flight but is the freeze stress response. In this place a person is stuck in a high state of arousal, fear, and distress but is paralyzed to do anything about it. In animals this involuntary response to extreme fear is called tonic immobility and can be seen when in the face of a predator that cannot be outrun or defeated, an animal like a possum will “play dead” to protect from death or prey. A deer may go into this state and while the cheetah drags its body to the bushes to hide it from other predators and to go grab its cubs, the deer can escape the bushes, shake off the arousal energy stored in the body, and escape the threat.
For children who froze as a response to extreme stress during their development, they may develop a tendency towards disassociation, depression, anxiety or panic disorders, and even post-traumatic stress disorder as adults. As a habitual response to stress, dissociation can be one of the most harmful ways one freezes. Disassociation is where we check out of ourselves in order to avoid the stressor, and a person who struggles with it might regularly feel disconnected from their surroundings, zoned out and unable to respond, have trouble with procrastination and isolative behaviors, or even feeling detached from reality.
An additional stress response that’s recently gained consideration that is not currently included in the stress response model is called fawning. Fawning is the response marked by people-pleasing behaviors, conflict avoidance, unable to find one’s voice or ability to stand up for themselves in the face of a threat, and taking care of the needs of others to one’s own detriment. These show up in the kid that was “the good kid” growing up. Always making good grades, never rocking the boat in order to not add fuel to fire to a family where there was already conflict or struggle whether it be with poverty, marital conflict, or just simply because the space or the parent did not welcome the child’s emotions and vulnerabilities . These children learn to adapt to stress and trauma by holding it all in, and in turn developing issues with anxiety and depression and are not practiced in expressing, releasing, and receiving soothing through attachment and bonding.
In children who adapted to stress by mobilizing (fight/flight response)-staying busy, playing in all the sports, as adults they may become the “producing type,” a term from the Hakomi somatic therapy approach, characterized by perfectionism, exhaustion, not much connection to others, and someone who feels valued only by their achievements. Or the “self-reliant type,” who acts as if they have no needs and like no one can be depended on therefore they must do it all themselves.
While we can all have these types of characteristics in our personalities, when one of them becomes rigid and domineering, it can lead us to lose connection to ourselves, our own needs and feelings, and to the natural world and the people in it; this inevitably will cause depression and anxiety. Furthermore, the brain and the nervous system of the adult has been entrained and imprinted to assess safety and danger in a person’s early childhood development. This means that in order for a person to rewire their imprinted nervous system responses from childhood, the “danger” arousal systems and the “safety” soothing systems of a person’s nervous system and brain must be worked with in order to re-print or re-pattern their nervous system. Nervous system re-patterning is a slow, tracking process that requires the skill of a somatically trained therapist. More info on this process here: Nervous System Re-Patterning.
Attachment and ketamine treatment, who’s in the treatment room and what are they doing?
As humans, we are creatures that form bonds that meet our needs for safety and companionship especially in times of distress. Anyone who’s gone into surgery or taken their child in for a shot, knows that often a child needs to be held or to hold the hand of the parent in order to tolerate their fear. A spouse needs to be accompanied at the hospital by their loved one in order to have the reassurance to go into surgery. As humans we grab and reach for each other in times of challenge, fear, or danger, this is also known as the attachment cry or reach, that we see in babies and we all have inside of us when we are in distress. We want to reach.
That primal grab or reach is the very reason why in seeking out ketamine treatment clients should be accustomed to asking from the start of their inquiry “who will be in the treatment room with me during the treatment?” In some clinics, the medicine is administered by a doctor or a nurse and then the client is left alone in the room for the duration of their psychedelic experience. This is one of the more problematic medical models of ketamine treatment, especially for those who have attachment/developmental trauma (which are most clients). While not ideal, the clinic may be understaffed or in a rural community and therefore having a few helpful tools to take with you into this type of clinic model can create a safer-feeling “holding environment” for the client to have a positive healing experience. For these tools you can check out the Ketamine Consumer Checklist.
Another model of ketamine treatment that does not include therapy during the ketamine session is through the company Mindbloom. Many consumers looking into ketamine treatment will share that they began getting ads from Mindbloom on their devices. Clients are offered a low price model where they take the medicine in their homes by themselves and then speak to a “guide” afterwards, sometimes for 30 minutes. It is unclear who the guides are although their website does say that they are “licensed” guides, which is ambiguous. My understanding is that many of the guides are not licensed therapists and again they are not present during the psychedelic experience.
Sadly, these models portray the somber picture of the capitalistic and individualistic ideals our society has trumped and that have also led to the very sickness we are trying to heal. Our society that praises independence and self-reliance and then asks why we have so many suicides. The large scale operations of Mindbloom as well as the non-therapy ketamine treatment models are turning their backs on the isolated, lonely adults who as children were also not given the attention, love, and care they needed, and still are being deprived, even from the very professionals claiming to heal. For more on the sickness of an isolated and lonely society check out this blog post: Healing Loneliness with Psychedelics.
For a harrowing look at the dangers of psychedelic therapy becoming capitalized for profit only and loosing the humanity of its cause, check out the short story book created by loving, caring, leaders in the psychedelic therapy field, We Will Call It Pala.
Monkeys and Attachment
During the 1960s a series of controversial experiments conducted by American psychologist Harry Harlow, demonstrated the powerful effects of love and in particular, the absence of love. In the famous experiment he gave young rhesus monkeys a choice between two different "mothers." One was made of soft terrycloth but provided no food. The other was made of wire but provided nourishment from an attached baby bottle.
In the experiment young monkeys were separated from their natural mothers a few hours after birth and left to be "raised" by the mother surrogates. The experiment demonstrated the baby monkeys spent significantly more time with their cloth mother than with their wire mother.
The infant monkeys went to the wire mother only for food but preferred to spend their time with the soft, comforting cloth mother when they were not eating. Harlow concluded that affection was the primary force behind the need for closeness.
Later research demonstrated that monkeys would also turn to the cloth surrogate mother for comfort and security. The work revealed that affectionate bonds were critical for development. Young monkeys were allowed to explore a room either in the presence of their surrogate mother or in her absence. Monkeys who were with their cloth mother would use her as a secure base to explore the room. When the surrogate mothers were removed from the room, the effects were dramatic. The young monkeys no longer had their secure base for exploration and would often freeze up, crouch, rock, scream, and cry.
Somatic attachment-based ketamine therapy
Luckily, we have other options between tericloth and wire when it comes to offering a secure base for a client to safely explore inside the context of their psychedelic journey. With a trauma-trained psychotherapist as a guide, an adult can be lovingly, and compassionately stewarded towards their younger, wounded, inner child parts in order to have those younger parts grieve, emote, express, give voice, and receive support, love, and attention both by the therapist and by the adult client.
In a psychedelic journey, a person who may otherwise be overwhelmed with fear in their waking life, has the opportunity to freely explore the psychedelic experience of landscapes, memories, images, feelings, thoughts. And for the client to have a secure base in the form of a therapist that they’ve developed a relationship with prior to the journey, means that they can more safely explore a new and uncertain environment. Should they come across an obstacle in that exploration, the therapist serves as the secure base for regulating fear and regaining a sense of confidence to continue exploration. Just as the monkeys in the experiment froze up and cried without the secure base of their surrogate mother, clients without proper support and holding by trained and licensed mental health providers can have re-traumatizing, damaging experiences that only serve to worsen their mental health symptoms.
Should a client reach a point in their psychedelic journey that is challenging, distressing, confusing, or scary, the licensed therapist can offer the client supportive, soothing, attachment-based words of comfort, reassurance, security and safety. Many somatic trauma-trained therapists will have knowledge of the nervous system and how to regulate stress responses and fear activation in a client. Just as a caring parent uses their nervous system, body, and voice to pick up and soothe a crying baby, a somatic trauma-trained therapist will have the tools to use their own nervous system to soothe and regulate a person who may be in distress or in a re-traumatizing experience in the ketamine treatment. This theory of soothing and regulation of the autonomic nervous system that is responsible for cueing the brain/body on safety and danger, is derived by behavioral neuroscientist Steve Porges and his Poly Vagal theory.
If the therapist has been trained in touch they may also offer to hold the clients hand or provide holding on the shoulders or feet of the client. Touch is one of the most grounding and soothing tools that we have as humans and unfortunately there have been countless harms committed involving touch. For this reason anyone who is using touch within any psychedelic or therapeutic realm should have proper training in order to protect clients and provide informed, safe, non-sexual therapuetic touch. Any agreements on touch can and should be made ahead of the ketamine therapy before the client is on the psychedelic medicine.
Disneyland on the moon and back with this stupid T-shirt
Without the guidance of a licensed therapist during the ketamine treatment as well as in the pre and post sessions for preparation and integration, a person looking to relieve their mental health issues can end up with a high medical bill without much to show for it. While they may experience relief from suffering during the medicine experience (a sparkly vacation from their normal state of consciousness), without a therapist to work with the attachment wounding or the trauma that caused the suffering of depression and anxiety, they are likely to revert to the default mode of operating and perhaps even feel an increase in depression and despair having invested and failed.
In my practice I had someone reach out seeking ketamine-assisted psychotherapy (K.A.P or K.A.T) after he had spent over $10,000 on ketamine treatment with a medical doctor and had little lasting results in his mental well-being. This was not the first of this type of call that I’ve received. This person was alone in the medical office room during the ketamine treatment sessions and after the sessions he met with a doctor who asked him questions about how he was physically feeling. There was no psychological guidance or therapy during or after the ketamine treatment. Even if someone like a nurse or doctor had been in the room with this person they simply do not have the psychological training to be offering mental health care and therefore should be accompanied by a licensed therapist, ideally one who is specifically trauma-trained.
Should you be in a situation where there is no therapist available in your region or local ketamine clinic, one option is to have a therapist support you in the before and after stages of the actual ketamine treatment. A therapist can be hired to support your process by creating an intention and plan for your ketamine treatment and helping to prepare you for the experience, and to create a container after your ketamine treatment to process, make meaning, integrate, and extract insights from your experience that can then be used as on going practices to sustain your mental health. Some of these therapists can be found here at Psychedelic Support.
The future of ketamine therapy
Ultimately the beauty of this treatment is in the collaboration or hybrid model, of combining the medical world with the mental health world. In honoring the uniqueness in education and skill each field brings to the treatment, each provider offers their expertise around what they can offer, and their ethics on what they cannot. Unfortunately while a therapist would have a very hard time bypassing the legal requirements of the medical field by obtaining the medicine or prescribing it themselves, and it would be totally illegal, medical professionals are operating medical AND mental health treatments freely without any requirements for collaborating with a psychotherapist or licensed mental health professional.
Ketamine clinics that are not currently using licensed mental health professionals in their ketamine therapy process should consider the ethics of their treatment model and in doing so contact local therapists to inquire on hiring opportunities. Furthermore, for mental health symptoms to stay in remission, on-going individual therapy with a licensed mental health professional is highly recommended. This is where the rubber meets the road in the maintenance of exercising the behaviors and perspectives that reflect the insights afforded in the ketamine treatment. Every ketamine treatment operation should therefore provide a referral list of local therapists to each client who undergoes the ketamine treatment, and with a recommendation of at least 6 months of on-going individual therapy. If financial resources are limited, sliding scale therapy options can be accessed through a website called Open Path.
As we as a society progress in opening our minds to the healing opportunities afforded in psychedelic therapy, so too should our policies and ethics progress and align in order to protect the well-being of patients, clients, and mental healthcare consumers. In the true collaborative spirit of humility and connection, I believe that medical professionals and mental health professionals can honor and value their differences in expertise and form strong treatment teams to facilitate ketamine therapy treatment from the strongest point of all, connection.
Click here for the Ketamine Consumer Guide on what questions to ask when approaching a ketamine treatment provider and how to prepare for a medical clinic model treatment.
https://www.ashleytreatment.org/learning-about-stress-responses/
https://www.verywellmind.com/harry-harlow-and-the-nature-of-love-2795255
https://mcasa.org/newsletters/article/trauma-and-the-brain-understanding-tonic-immobility