Different Approaches to Working With Ketamine

Generic ketamine is not yet FDA approved to treat mental health conditions, and is used off label in treating resistant depression, bipolar depression, and suicidal ideation. There is also evidence that ketamine may help treat anxiety, OCD, eating disorders, PTSD, and alcohol use.

As I observe the landscape of ketamine clinics working with mental health conditions, I notice a rather pronounced divide in ways of using ketamine for healing. I recently read an article by Raquel Bennet, a trailblazer in the ketamine field, which discussed various paradigms of working with ketamine. This blog was inspired from her brilliant analysis.

Approach #1: Ketamine as an antidepressant medicine

The first approach understands ketamine’s antidepressant effects on a chemical level, similar to how chemotherapy may be offered to a cancer patient. In this model, the client is a passive recipient, and the medicine does all the healing. This model is aligned with the current Western model of medicine. Some ketamine clinics that subscribe to this model put less emphasis on the setting of the clinic, preparation for the treatment, the relationship quality with the provider, and often are disinterested in the psychological material that arises during the ketamine treatment. I’ve noticed that oftentimes clinics that emphasize this model are run by medical providers with a lot experience giving ketamine, but little to no training in mental health or psychotherapy.

Most of the research done on ketamine’s antidepressant effects has tested this model, and found a large body of evidence showing that a group of multiple ketamine treatments can improve depression in 70% of patients who haven’t responded to other antidepressants. Although this is a stunning statistic, it’s important to understand that after an initial group of six ketamine treatments, the antidepressant effects often wear off in a month. Thus, within this model, many patients with depression require monthly booster ketamine sessions.

Approach #2: Combining ketamine with talk therapy

The second approach, practiced more by mental health professionals and psychologically informed providers, emphasizes the patient’s life experiences beyond a diagnostic label. Exploring the patient’s narrative, life stressors, and ingrained patterns of thinking contribute to a deeper understanding of the patient as a person. These ketamine clinics may use ketamine as a tool to help the client understand and overcome potential psychological hurdles in addition to the purely molecular mechanism of action. By going to the roots of the problem, these providers are hoping for a stronger and more sustained antidepressant response.

Although there is still only a small amount of research on combining therapy and ketamine, there is a strong rationale for how talk therapy may augment and sustain the antidepressant effects of ketamine. Part of how ketamine is postulated to work is through enhancing the neuroplasticity in the brain. It is thought that during and soon after ketamine treatments, the brain may be better able to learn new things, including new ways of looking at oneself and the world. In addition, during ketamine treatments, our “default mode network” (which is related to depression and rumination about the past and future) is turned down, thus opening up space for healthier perspectives.

A recent research article appeared in the peer-reviewed American Journal of Psychiatry which lends support to the idea that psychological interventions given soon after ketamine may sustain the benefits of ketamine. Interestingly, the psychological intervention used in the study was a computer learning program, which trained participants to have positive self-associations. If a computer program can help leverage the effects of ketamine, imagine the benefits of working with a skilled therapist.

Approach #3: The psychedelic and mystical experience of ketamine

At slightly higher ketamine doses, patients may have psychedelic and mystical experiences, and there is less talk therapy during the session. Some may feel their ego dissolve or have mystical and spiritual experiences. These experiences may lead to seeing oneself and the world in new ways. There is often much rich new learning one can integrate from exploring these experiences in follow up therapy sessions.

Which Approach is Right for Me?

One size does not fit all. Understanding the different approaches to ketamine may help you assess your own needs and goals for treatment. Speak to different clinics and see which approaches they utilize. Feeling comfortable and trusting your provider is perhaps the most important ingredient to getting the most out of your ketamine treatments.