Ketamine’s off-label use for depression has increased steadily since the treatment’s efficacy was established in 2006. But in 2020, as many medical practices moved online to continue seeing and treating patients, ketamine went digital, and companies offering ketamine specifically designed for at-home use emerged on the scene. For some, simplified in-home access supported mental health during a particularly challenging period. Others foresaw challenges around dosing and dependency, some of which have played out. Increasing ease of access to ketamine has raised vital questions about when – and how – ketamine is best administered.
As interest in ketamine as a mental health treatment continues to grow, what should therapists know about this drug with a long history of off-label use, and how can they begin their own training in ketamine-assisted psychotherapy (KAP)?
There are two models of ketamine administration: the pharmacological, when ketamine is offered as a standalone drug treatment, and the psychotherapeutic, when ketamine is taken with a therapist present. While some people do benefit from the medical model of treatment, risks of using ketamine can be heightened without a therapist present. Training programs prepare mental health professionals for the second model in particular.
From Historic Use to Present-Day Potential
Ketamine was synthesized in 1962 by chemist Calvin Stevens. In 1966, it was patented for human use as an anesthetic. Its off-label use for treatment of mental health disorders began in 1970, when physicians combined intramuscular ketamine with psychotherapy. In 2006, Dr. Carlos Zarate (of Yale University and the National Institute of Mental Health) published research establishing ketamine’s efficacy for treatment-resistant depression. While the FDA has not granted generic ketamine approval for treating depression, research continues to show its effectiveness.
Despite this research, ketamine is not a firstline treatment for depression, notes Dr. Elizabeth Nielson, co-founder of Fluence. “Ketamine is still off-label for depression, and there are approved firstline treatments, such as traditional SSRIs, that we have data demonstrating the safety and efficacy of. In general, I recommend a patient try, or at least explore, those approved treatments first.”
When firstline treatments do not help, or when patients have contraindications or difficulty with side effects, ketamine may be an appropriate next step. Unlike SSRIs, Nielson points out, ketamine does not need to be taken every day, and it does not cause side effects like weight gain or loss of libido. Schedules and protocols are also determined individually for each patient. “That’s a very different relationship to have with a treatment as opposed to having to take a pill every day,” Nielson says.
Rebecca Kronman, LCSW, a KAP practitioner and a trainer at Fluence, adds that “Ketamine takes effect very quickly, in seconds or minutes, with the antidepressant effect (potentially) setting in quickly as well, often right after the acute effects of the altered state wear off.” In contrast, she notes, “SSRIs can sometimes take up to 6 weeks to feel the effects.” In cases where patients are actively suicidal, the swiftness of treatment could be life-saving.
Ketamine’s side effects are important to clarify before someone begins treatment, though they are relatively uncommon. Physiological risks, Nielson notes, include bladder issues like urinary retention and other problems stemming from that. More rarely, respiratory complications occur. Ketamine also has the potential for abuse. For all of these reasons, having a plan for dosing and frequency managed by a clinician is important.
She adds that the experience is “an intense non-ordinary state of consciousness for people that can be frightening, emotional, blissful, and wonderful – and can also be destabilizing if people don’t have the support or wherewithal going into it to manage it.”
This makes integration another key step of working with a medicine that, as Kronman explains, “flips the Western medical model on its head. We are used to picking up a prescription and taking it every day in order to hopefully feel the cessation of our symptoms. With ketamine, you’re educating the client about how that is not really the case with this medicine. If you just take it and do nothing else, you will have an interesting day – and possibly a few days afterward where you’re feeling ok – and that’s basically it.”
The therapeutic element helps people navigate the post-treatment process, Kronman says, whether it’s in-office or virtual. “Without active participation in this process, there will most certainly be very limited value to doing work with ketamine, especially because people often experience a trip that is particularly ineffable.”
That can differ from working with other psychedelics, she notes, which often give people an experience of “downloading major insights about their lives that feels pointed and direct.” But, she says, “ketamine can be more vague. It’s more of a winding path, and the arc can feel long between the trip and feeling that the work has been integrated into one’s life.”
What Happens in Ketamine-Assisted Psychotherapy?
A ketamine-assisted psychotherapy dosing session typically lasts up to two-and-a-half hours (with approximately 90 minutes of active journeying).
Prior to the dosing session, practitioners spend time educating patients about the therapy process, preparing them psychologically and supporting them as they set intentions and develop practices for working with potentially difficult experiences.
During the session itself, a therapist provides reassurance and takes care of the setting to ensure the patient can be fully immersed in their experience. Unless a therapist is also a licensed prescriber, patients will self-administer the ketamine during the dosing session.
After the session, the therapist continues to support the integration process. “The first part of that is just asking, ‘What did you experience?’’” says Kronman. “Then, we can engage in a meaning-making process around that material and the client can decide where to go deeper.”
Training programs like Fluence’s are deep dives for mental health professionals who want to become experts in this field. They may offer observational practicums with experienced KAP practitioners, webinars on topics like access and inclusion in psychedelic treatment, electives, mentorship, practice in conversations around patient consent, and even discussion groups and bookclubs. Participants can expect trainings to run up to 150 hours over one year.
Fluence, in particular, also grounds their program in what Kronman calls “intuitive healing wisdom” – the idea that the client leads the way. That model can be different for many therapists who may be trained to point the way or act as the expert in a therapy session. “We have to unlearn some of that,” she says, “and learn different ways to allow the client to access their own healing wisdom.”
When Kronman trains therapists in KAP, she continually emphasizes the ownership clients have over their own healing processes. “Clients need to understand how they activate this work on their own and engage with the medicine by leaning into personal contemplative practices and beginning to look at behaviors and circumstances in their lives that might contribute to their unhappiness,” she says.
She also hopes more people will be drawn to this work from diverse backgrounds. “The field is still in great need of diversity,” she explains. “We want individuals to be able to find practitioners who look like them, come from similar culture or racial backgrounds, and who understand that there are varying levels of socioeconomic access for this work, which is taking place in a very privileged vacuum at the moment.” While she and other KAP practitioners are working to get ketamine-assisted psychotherapy covered by Medicaid in the hopes that insurance companies will follow suit, “practitioners have to take it upon themselves to find ways to attempt to make this work more accessible. Part of accessibility is access to a greater variety of people.”
And what about ketamine going remote? Both Nielson and Kronman acknowledge that there are important reasons why a KAP session would happen remotely, including, again, issues around accessibility for both the client and the therapist. Kronman does note that if a patient is already struggling with feeling disconnected, an in-person session might be preferable. And, unless someone is going to an infusion clinic to “bring up the baseline and help them feel a little more resourced,” ketamine-assisted psychotherapy, whether virtual or in-person, often supports the patient to “hold challenging material in the aftermath” of a session.
“Ketamine can be a very big experience, and we want to make sure the holding environment is safe and we are prepared for it,” she says. “A lot of ketamine work is done in a way that’s kind of swift and not necessarily exploratory of all the things that could come up,” she says. “We want to establish a way to prepare for those things.”