Ketamine-Assisted Psychotherapy: An Integrative Approach to Treatment

by Tom Neilson, Psy.D.

Psychedelic-Assisted Psychotherapy is all over the news these days. Following the success of Michael Pollan’s book and recent Netflix series, How to Change Your Mind, there is much excitement over the healing potential of psilocybin, MDMA, LSD, and other psychedelics. Psilocybin-Assisted Psychotherapy and MDMA-Assisted Psychotherapy have been so effective in the research to date that they have been granted breakthrough therapy status by the Food and Drug Administration. Breakthrough therapy designation is a way to expedite the development and review of new drugs when preliminary research indicates that the drug may demonstrate substantial improvement over available therapies.

There is only one problem with this rosy picture: these medicines have not yet been granted FDA approval, and they are not available to the public outside of research studies. However, one psychedelic medicine, ketamine, is available for treatment now. Ketamine is not a classic psychedelic like psilocybin or LSD; it is a dissociative anesthetic that has psychedelic properties at lower doses.

Several practitioners in the Nashville area are offering ketamine intravenous infusions, which have been shown to be an effective treatment for treatment-resistant depression and Post Traumatic Stress Disorder. Daniel Barton, M.D. has been an innovator in the field, and others have followed his lead. However, few practitioners are combining ketamine with psychotherapy in middle Tennessee. Ketamine-Assisted Psychotherapy (KAP) is a promising, integrative approach to treatment that aims to combine the best of the therapeutic power of ketamine and talk therapy.

KAP, in contrast to ketamine infusions, pays attention to important psychological factors in the client’s healing. It aims to optimize treatment by carefully preparing the client, offering a pleasant and supportive environment for treatment, integrating the insights of the ketamine experience, and using all the available tools of psychotherapy. During KAP, the client always has a therapist present, which is often not the case for people receiving ketamine infusions. The presence and the support of the therapist helps reduce any anxiety and fear and makes the experience more comfortable.

How Does it Work?

KAP is a remarkable, integrative approach to psychotherapy that combines the effectiveness of psychotherapy with the latest in neuroscience and psychopharmacology. Here is a summary of several mechanisms that appear to play a role in the effectiveness of KAP.

The Default Mode Network (DMN). Ketamine, like psilocybin and other classic psychedelics, quiets the brain’s default mode network (DMN). The DMN is a network of brain structures that help the brain operate in an efficient manner, by working mostly on habit. By quieting the DMN, ketamine helps people break old habits and get out of mental ruts.

Disrupting rigid patterns. Many mental disorders, including depression, anxiety disorders, and addictions, are characterized by excessive rigidity (or excessive order) in thinking, feeling and behavior. Examples include the tendency of depressed people to get stuck in rumination about the past or about how inadequate they feel, the tendency of anxious people to obsessively worry about the future, and the tendency of those with addictions to ruminate about their next fix. Ketamine appears to interrupt these rigid patterns, introducing creative dis-order, allowing the individual to develop new, healthier ways of thinking, feeling, and behaving.

Increased Compassion and Empathy. At lower doses, ketamine operates as an empathogen: it can facilitate greater compassion and empathy. This helps in developing self-compassion, which is a powerful antidote to the self-critical thinking common in depression. It can also help in the development of greater compassion and empathy for others, which can facilitate couples’ therapy.

Neuroplasticity. Ketamine is also a neuroplastic agent; it causes the growth of new neurons and new synaptic connections via the release of a protein called brain-derived neurotropic factor. This allows a re-wiring of the brain which alsofacilitates the development of new, healthier ways of thinking feeling, and behaving.

Anti-Inflammatory Effects. Recent research suggests that chronic, low-level inflammation from childhood stress,chronic stress, infections, gut bacteria, autoimmune disorders, and other sources can cause depression. Depression isincreasingly understood as a disorder of inflammation in the brain. Ketamine has anti-inflammatory properties thattreat the chronic inflammation associated with depression.

Psychotherapy. In Ketamine-Assisted Psychotherapy, a therapist works with the client in developing new and healthierhabits of thinking, feeling, and behaving. The therapist uses all the tools of psychotherapy to assist the client’s growthand change. Treatment approaches including Mindfulness, Internal Family Systems (IFS) and Acceptance and CommitmentTherapy (ACT) are commonly used. There is a remarkable synergy in this integration of psychotherapy andcutting-edge neuroscience.

Peak or Mystical Experiences. It is common for clients to have positive peak experiences during KAP, such as feelingone with everything, discovering deep compassion and love for self and others, or having an experience of the presenceof the divine. These experiences tend to be profound and are often cited as one of the most important and meaningfulexperiences that clients have in their lives. Roland Griffiths, Ph.D., a professor and researcher at Johns Hopkins Schoolof Medicine, suggests that these peak experiences can cause “inverse PTSD.” By this he means that these experiencesare so positive and affirming that they have a healing and restorative effect, leading to a richer and happier life, which isthe opposite of what happens when a serious trauma causes Post-Traumatic Stress Disorder.

Tom Neilson, Psy.D. is a clinical psychologist in private practice in Nashville, TN. He has worked in the community mental health field, has been training director of an APA-accredited internship program for psychologists, and has been in private practice for 25 years. His doctoral degree is from Florida Institute of Technology. Tom graduated from California Institute of Integral Studies’ Certificate Program in Psychedelic-Assisted Research and Psychotherapy in 2021, and he has received specific training in ketamine-assisted psychotherapy at Polaris Insight Center. He is currently chair-elect of NPI.