Ketamine Is Powerful, but Therapy Is the Thing!

Psychedelics are not, by themselves, reliable agents of change. Rather, psychedelics can offer moments of revelation and epiphany that can be leveraged into change.

It’s right in the name: psychedelic-assisted psychotherapy. Psychotherapy is what the psychedelics are there to assist. Psychotherapy is the lever.

K-Holes and the Role Psychotherapy

One colloquial way to describe a psychedelic dose of ketamine is entering a k-hole. There are various dosages people may use in the course of their work with the medicine. A low psycholytic dose can be used to create the feeling of a gentle meditation. Sometimes patient and therapist may mutually decide on a full psychedelic dose, and it may beget a very surreal experience, much like a lucid dream that seems quite bizarre, in which the person does not have full use of their faculties and might even lose sight of where they are. That is the trip, and k-hole is not a terribly inaccurate description of that experience.

One key difference between recreational versus therapy-focused use of ketamine isn’t the absence of a k-hole but rather a thoughtful selection and curation of the k-hole. There are patients who prepare to enter the k-hole weeks before they ingest the medicine.

Preparing the Unconscious

Psychedelic-assisted psychotherapy consists of three differently themed/structured sessions: preparation, medication, and integration. A lot happens in early preparation sessions, including evaluation for candidacy, managing of expectations, and designing the right protocol. The bulk of preparation, however, is curation of the client’s intentions for their medicine session. What material do they want to engage, what questions do they have for their inner healer, what are they seeking from the treatment?

Over the preliminary sessions, as well as in future sessions in between each additional medication session, patients pick/hone/direct their thoughts and energies and attention to their target of healing. Such focus awakens their unconscious awake, attunes it to the medicine session, in which the client will dance with the theme they chose.

Obviously, it is no guarantee that the medicine session dream will track with the curated intention. But it usually does, and, sometimes, even if it isn’t the k-hole that was planned, it turns out to still be the right answer to the intentions set.

Epiphany/Revelation and the Role of Psychotherapy

Sometimes people talk about a recreational psychedelic trip in their 20s that “changed their life”. It can happen, the way a cancer survivor’s world view can be forever altered upon diagnosis or recovery, how a magical conversation with a stranger opens a new understanding that changes the direction of one’s life, or, when faced with another’s suffering, life-long gratitude can be awakened.

But way more common is that someone learns a new thing, sees a new thing, understands a new thing, and then returns to their same old world and self-view, same old patterns, same default-mode thinking and processing. Humans can easily return to their own twisted form even after glimpses of freedom.

Integrating Psychedelic Experience

Integration of the psychedelic experience is the true north of this work. The epiphanies, revelations, awakenings, realizations, perspectives, must be explored, understood, operationalized, brought into existence in daily life. Or else they were just a cool experience.

Ketamine Offers a Lucid Dream

I like to describe the ketamine experience as a lucid dream state. Because of the dissociative and anesthetic properities of ketamine, the “trip”, which typically lasts around 20 to 40 minutes, presents much like a dream, but with a capacity for some influence over what is happening in the dream state.

When we talk about dreams, we are talking about the unconscious. The classic psychedelic-assisted psychotherapy language of “inner healer”, “inner wisdom”, and “wise self” can be understood in many frames, but certainly for psychotherapists, it is the realm of the unconscious. The medicine session is an opportunity for both client and therapist to collect information, in dream-form and somatic experience. Sometimes in colors and sounds, sometimes in images with whole story lines, the unconscious delivers up a collection of thoughts/feelings/memories/experiences/ associations for both therapist and client to add to their understanding.

Having had the dream, though, the work is still in untangling it, deciphering it, finding its heart-and-soul and lessons. This is work of deep contemplation, traversing the inner landscape to understand how the new material and understanding can re-form one's internal core. It is simply not enough to have had a cool dream/experience, but to use it to help change and free people.

Therapy Essential Reads

Presence in Therapy: Feeling Safe and Challenged to Grow

What Acceptance and Commitment Therapy Research Tells Us

Psychedelics without Psychotherapy Is Like Leaving Money on the Table

There are two common scenarios in which people use prescribed ketamine without psychotherapy. They surely are still getting benefits from the use, but wow are they leaving money on the table!

• IV Infusion Centers: There are times when this is the best or at least an appropriate way to get ketamine treatment, for instance for treatment-resistant depression or for someone who needs blood-pressure monitoring. Psychotherapy may not be part of their plan. It's worth adding it! Ketamine might reduce the symptoms of depression—which is wonderful —but why not use the psychedelic experience to also reveal new understanding and try to heal? Therapy can be used to prepare for medicine sessions so one enters them with clear, simple intentions, and, during the weeks of treatment, to explore the surfacing material during and after sessions, and how those experiences are impacting daily life. The ketamine treatment period can be filled with glorious and rapid change. Facilitate that.
• Prescribed for at-home unmonitored ketamine treatment: At home unmonitored ketamine treatment doesn’t mean without therapy. That just means there isn’t a therapist required to be present with the client during the medicine session itself. Patients absolutely should still be doing all the preparation and integration sessions, and likely occasional monitored medicine sessions, throughout the period of prescribed at home use—or else the big tool for leverage and integration is being left on the table.