What to Know About Ketamine-Assisted Psychotherapy

Evidence suggests that for psychedelic treatments to achieve maximum efficacy, a trance-like dissociative state is necessary

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Part 1 of this series provided an overview of essential information about ketamine for psychiatric use; this post will focus on ketamine-assisted psychotherapy.

Ketamine-assisted psychotherapy (KAP) can encompass many different things. Treatment settings can range from exotic, remote locations (as per a ketamine retreat) to the more mundane, like a ketamine clinic or psychiatrist’s office. Similarly, psychotherapy in this modality can be a single session with a therapist you’ve just met or it can involve a series of sessions with your regular therapist.

Given that research into KAP is at a very early stage, there are few review articles on its efficacy, and those that exist examine just a handful of studies, with most having small sample sizes, so the findings need to be taken with a grain of salt. However, in one such review by Drozdz and colleagues (2022), the authors reported that, in general, KAP can “prolong clinically significant reductions in pain, anxiety and depressive symptoms” and that “longer-term psychotherapy may be helpful in sustaining these gains.”

Dore and colleagues (2019) explored the efficacy of KAP within a psychoanalytic framework in the first such study of its kind. Data were collected from 235 patients, across several diagnostic categories, and ketamine treatments ranged from one to 25 sessions. The authors reported significant decreases in anxiety and depression (relative to baseline) with combined treatments of ketamine and psychoanalytic psychotherapy. They also reported that the number of KAP sessions was significantly positively correlated with improvements in depression and anxiety.

How KAP Might Improve Psychological Well-Being

There seems to be a consensus forming among researchers and practitioners that, for psychedelic-assisted psychotherapy (PAP) in general, and KAP specifically, a psychedelic/dissociative/trance state needs to be achieved during the session for maximum efficacy to be achieved (Dore et al., 2019; Drozdz et al., 2022; Joneborg et al., 2022). Dore and colleagues even went so far as to report that no study to date on KAP has demonstrated an antidepressant effect without some degree of perceived psychoactivity. In speculating why such a dissociative/trance state may be necessary, Dore and colleagues suggested that the trance state produced by psychedelic drugs “promotes communication, access to difficult states of mind with less fear of those encounters, and a relief from obsessive and depressive concerns.” My clinical work with numerous patients receiving different forms of PAP validates Dore and colleagues' assessment.

In a recently published case report (Cottone, 2023) I presented specific details of a KAP session with a long-term, psychodynamic psychotherapy patient, "Elizabeth"; an abridged version of this report is presented below. My KAP session with Elizabeth demonstrates why Dore and colleagues’ assertion may be true, as it seems that ketamine temporarily lessened her defense mechanisms, allowing us to elucidate connections in her life, as well as possible causes of her symptoms (with related interventions to treat them), in a way that would not have been possible without the psychedelic experience. Apropos of this, I believe that analytic/psychodynamic psychotherapy is uniquely suited for KAP given the importance placed on deconstructing defense mechanisms in the approaches from the Freudian tradition.

Case Report

Elizabeth began psychodynamic psychotherapy with me in 2019, about 8 years after a tragic fall that left her with permanent spinal damage and chronic pain. Stemming from this incident, as well as earlier sexual assault when she was 15, Elizabeth exhibited clear symptoms of posttraumatic stress disorder (PTSD). In addition to these traumas, her most recent slow-motion trauma is the progression of primary lateral sclerosis (PLS), a variant of ALS.

Before her injury, Elizabeth had strong (if not blind) faith in the medical establishment; however, after complications from multiple surgeries worsened her condition, and post-surgical regimens became increasingly problematic, Elizabeth’s faith in all things medical began to erode. Despite this, it’s notable that from the beginning of treatment, Elizabeth was bent on idealizing me, epitomized by her insistence in calling me by my initials: JC. This was especially ironic because she abandoned her Christian faith earlier in life. This aspect of Elizabeth’s transference was my first experience with her tendency to conceive of important people in her life — including her wife, Stephanie, her closest friends, her parents, and me — as “superheroes.” (All names changed to preserve privacy.)

Source: Pat Loika / Wikimedia Commons

Dynamics between Elizabeth and her superheroes often led to one of two types of problems. First, in Elizabeth’s eyes, her superheroes could do no wrong, and this invalidated the experience of anyone in her life who had ever been hurt by one of them. Second, whenever there were conflicts in Elizabeth’s life involving two of her superheroes, the ambivalence, anxiety, and tension that resulted would place her in a double bind. It’s here that her unconscious seemed to devise a creative, though uncomfortable, way to rescue her, as she would soon experience an exacerbation of her significant medical and physical needs. Consequently, seeing such an escalation of Elizabeth's physical pain and symptoms would elicit great concern among everyone in her life, including the two superheroes in conflict, ultimately leading to them laying down their arms and rallying around her.

Elizabeth began receiving racemic ketamine treatments once per week, in the fall of 2022, and though she was making considerable progress, she believed more was possible. She then requested that we have a psychotherapy session at her psychiatrist's office during one of her ketamine treatments, and in January 2023, we did just that.

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Over the course of this 90-minute session, Elizabeth took 200 mg of racemic ketamine via nasal spray (i.e., 20 sprays). While under the influence of ketamine, Elizabeth spoke about being able to “cut the cord” between her wife Stephanie’s emotional reactivity and her own, and she also noted a growing emotional distance between herself and her past traumas. She then described a “spiritual” experience, which was unusual given that she’d consistently denied any inclinations toward spirituality.

Later, Elizabeth acknowledged, for the first time, her tendency to make the important people in her life — including her wife Stephanie and her friend Diane — into superheroes in her mind. She discovered, over the course of our session, that her need to do this started after her sexual assault to help manage the terror she had as a teenager, and this tendency only increased after the additional medical traumas she endured.

Elizabeth noted that the feeling of calm she had while on ketamine gave her the emotional distance and courage she needed to see that idealizing people as superheroes helped her to maintain a fantasy that they could rescue her from her various hardships, which gave her the hope she needed to endure. She then noted finally understanding how her tendency to ignore the flaws of her superheroes led to increasing conflicts in her life, particularly between Stephanie and Diane.

At the end of the session, it became clear to Elizabeth that the impasse caused by two superheroes being in conflict with each other could only be resolved by an exacerbation of her symptoms, as this was the only thing powerful enough to get these individuals to drop their anger and rally around her. This insight was crucial because it helped her see that her physical deterioration had an indirect benefit. It's at this point that Elizabeth and I discussed the need for her to try harder to see the flaws of her superheroes, so as to validate those in her life who were hurt by them.

Immediately after our KAP, Elizabeth began applying this intervention, and in the months that followed the frequency of conflict between Elizabeth's superheroes significantly decreased, as did the number of times she reported an escalation of physical symptoms. Though Elizabeth has not achieved remission of her PLS symptoms, or those emanating from her spinal injuries, she’s consistently reported less physical pain, a greater range of motion, and sustained remission from her depressive symptoms. She’s also enjoyed a renaissance in her marriage with Stephanie and rapprochement with many other people in her life, including other mutual friends who had been in conflict with Stephanie.

Conclusion

This case demonstrates what’s possible when ketamine treatment is paired with long-term psychotherapy (especially from a psychodynamic perspective), as Elizabeth likely wouldn’t have acquired the insights and benefits that led to the decline in depression and physical pain she experienced with either treatment alone. Elizabeth had been undergoing ketamine treatment for months before our KAP session, and though the treatments did much to enhance her mood, she didn’t come close to achieving the insights she had when psychotherapy was added.

Similarly, in her psychotherapy sessions with me without ketamine, Elizabeth never felt safe enough to consider that the people in her life she idealized — including myself — were not literal superheroes, even if her psychological stability required that we serve in that role. However, during our KAP session, her defense mechanisms relaxed enough for her to briefly consider, for the first time, the consequences of her idealizing tendencies. The insights emanating from that session were so profound for her, they gave her the confidence she needed to make the changes in her relationships that we subsequently discussed.

To find a therapist, visit the Psychology Today Therapy Directory.