Ketamine and Psychotherapy

There is an increasing, although not entirely conclusive, amount of recent research indicating the effectiveness of the anesthesia medication ketamine as a tool in treating many psychological disorders (Borenstein, 2021). Esketamine, a derivative of ketamine, is used most frequently and is FDA approved for treating a range of conditions.

Research indicates that ketamine treatments are most effective when combined with concurrent psychotherapeutic intervention, particularly positive psychological approaches. Why is psychotherapy reported to be effective with ketamine? To answer this question, we must look at how psychotherapy naturally blends with three neurochemical benefits of ketamine to optimize treatment outcomes.

Three Benefits of Ketamine for Psychotherapy

First, ketamine causes an ephemeral dissociative state.

In many traumatic disorders, dissociation can be a debilitating chronic problem, preventing the patient from being able to even acknowledge the initiating conditions - let alone resolve them. However, with ketamine, the dissociative state induced is temporary, and ideally, should occur in a controlled setting with psychotherapeutic staff actively engaged. This temporary state can give the patient a brief respite from the underlying emotional dysfunction, allowing the psychotherapist and patient to address the originating issues, leading to potential long term relief. When the dissociative state runs its course, the psychotherapist can help the patient to cognitively re-align with a greater understanding of the formative issues that have led to the psychological disorder.

Second, ketamine engages the neurotransmitters glutamate (and GABA)

N-methyl-D-aspartate (NMDA), is a glutamate receptor. Ketamine effectively blocks the NMDA receptor from action, allowing for more glutamate to be present in the synapses (Furikawa et al., 2005). By balancing glutamate (an excitatory neurotransmitter) and GABA (an inhibitory neurotransmitter) the patient's other neurotransmitters can reach optimal homeostasis, leading to a marked reduction of anxiety and depression - subsequently, decreasing hyperarousal and rumination. This enables the psychotherapist to focus on the underlying events causing the patient's cognitive and affective dysregulation with a patient who is calmer and able to focus constructively on finding more effective ways to manage his/her condition.

Third, ketamine initiates neural pathway formation.

This novel component is particularly exciting for psychotherapy. It differentiates ketamine from many monoamine based psychotropic medications, including SSRI's, that have shown disappointing results (Rush & These, 2018). By blocking NMDA receptors, glutamate presence is increased, which mediates synaptic plasticity (Furukawa et al., 2005) . By taking advantage of new neural networks, the psychotherapist can work with the patient to create positive thought processes and memories, mitigating the effects of the previous negative feedback loops and rumination. This can literally give the patient a new opportunity to find relief and a more positive outlook overall. (Conversely, if a psychotherapist is not involved in helping to construct positive associations then the newly formed neural pathways can develop negative associations, leading to a worsened state for the patient.)

Summary

By taking advantage of the benefits provided by ketamine, psychotherapists can work with patients to achieve three positive, and cumulative, results. First, the patient can be helped to deal with his/her pain and trauma in a short-lived, removed (dissociated) state. Second, anxiety and depression can be calmed by ketamine's effects on glutamate and GABA, enabling a more logical examination of underlying causes of the patient's issues. And third, positive neural pathways can be formed, breaking the previous negative cycles and rumination.

Additionally, these three benefits all reduce sympathetic stress response mechanisms, including cytokine presence and resulting inflammation, which further improves psychological and physiological well-being (Comer, 2022).

Ketamine assisted psychotherapy is a relatively new treatment and requires more longitudinal research. And like any medication, ketamine produces side effects, which are beyond the scope of this post. Nonetheless, current research - and practitioner reports - provide promise for ketamine and psychotherapy as potentially beneficial treatments for resistant depression, anxiety, suicidal ideation, alcohol abuse, and post-traumatic stress (Psychology Today, 2022).