Drugs are powerful. This is one reason we, as a culture, like to place each drug into a specific category: healing or harming, licit or illicit, medicine or poison.
But the reality is often much messier than those simple dichotomies. It’s challenging to hold one substance in both realms at once, to acknowledge that, depending on dose and context, one person’s cure is another’s sickness.
Of course, that’s why good doctors are critical. A psychedelic drug like ketamine is a perfect illustration of these conflicts: When abused, it can be a source of great harm. In hospitals, it is an anesthetic (the original use of ketamine) and a necessary salve for incredible pain. And increasingly, in therapeutic contexts, ketamine is considered a promising treatment for depression, anxiety, PTSD, and trauma.
In his New York City practice, Harvard-trained psychiatrist Will Siu has found that low doses of ketamine administered in conjunction with psychotherapy are effective. He walks us through what ketamine is, what a ketamine-facilitated therapy session is like, and why he thinks his patients have had success with it.
(To hear more from Siu, listen to him on The goop Podcast talking about trauma, loneliness, and paths toward healing and connection. And to learn more about ketamine infusions, listen to the episode with psychiatrist Steven Levine.)
A Q&A with Will Siu, MD
What is ketamine?
Ketamine is a synthetic compound that modulates a neurotransmitter called glutamate. It has long been used in clinical settings as an anesthetic and analgesic. And it’s a psychedelic: In the right dose, it acts, as psychiatrist Stanislav Grof put it, as “a nonspecific amplifier of the unconscious process.” Ketamine hasn’t been getting as much attention as other high-profile psychedelic drugs, like MDMA and psilocybin, but psychiatrists have been using it safely as an adjunct to psychotherapy for nearly twenty years.
Its effect is dependent on how you’re using it: Dosage matters, as does whether it’s injected in the vein or in the muscle, taken by mouth, or taken intranasally.
Although it’s legal in therapeutic contexts, ketamine has a somewhat negative reputation: There are serious problems with people becoming addicted to intranasal ketamine and abusing it for nontherapeutic purposes. Some refer to it as the heroin of psychedelics. But at the right dose, it can have a pretty significant clinical impact. I find in my practice that ketamine can act as a jump start for a lot of emotional material that would otherwise take months to work through.
Why do you do ketamine-facilitated therapy in your psychotherapy practice?
Ketamine-facilitated therapy is a process that allows us to gain access to the unconscious. At low doses, ketamine produces a hypnotic or dreamlike state. During normal waking life, we have barriers and defense mechanisms that serve to push away unpleasant or intolerable memories, emotions, and phobias—feelings that we repress and store in our unconscious, where we can’t readily access them. Ketamine can break down those barriers and open up a filter to the unconscious. At higher doses, ketamine can be dissociative and produce deep, meaningful transpersonal experiences.
The rate at which someone can reach a breakthrough and come to terms with negative emotions is far quicker. A specific patient of mine blew me away with her ability to open up during ketamine-facilitated therapy after three or four weeks. It’s likely we could have reached that point of emotional release with just talk therapy, but it would have likely taken significantly more time.
Essentially, ketamine helps bring deep-rooted emotions to the surface, giving us a glimpse into the unconscious mind. The talk therapy helps us work through and examine those emotions in a safe and freeing environment.
What happens in a session of ketamine-facilitated therapy?
It’s a two-hour experience. When a new patient expresses interest in ketamine-facilitated therapy, I take a few regular psychotherapy sessions to get to know them before we start working with ketamine. In the first session I’ll go over medical and psychiatric histories, in addition to what medications they’re on. Ketamine is typically a very safe drug with few complications, so as long as there isn’t anything glaringly problematic, we can proceed.
That process of getting to know that patient goes on for a few more weekly hour-long sessions of therapy. After those initial three to four weeks of getting to know a patient, we’ll have a ketamine-facilitated session. Patients will lie down and take a prescribed dose of about 150 milligrams of ketamine in the form of a lozenge that goes under the tongue; it takes around ten minutes to dissolve. At the end of those ten minutes, most people will experience a body-tingling sensation and overall relaxation. I try to keep the environment in my office as conducive to that mental state as possible: My patients will use an eye mask, and I’ll have calming music on. There is a significant amount of dissociation during the experience—feeling like you’re not present in your own body, as if it’s difficult to move. It’s akin to being in a trance state, where you’ll access some old memories and things will just come to mind, especially if the music correlates to some of the emotions you might be feeling while you explore your unconscious state of mind.
Patients stay in a lying position for about an hour. Following that, the ketamine experience ends, and we discuss what came up for about a half hour or so.
Then there is the integration work. After the initial ketamine experience, we’ll meet weekly and talk about the experience—what emotions arose, what those mean to the patient, what they saw, and how they felt after the experience. We explore what was seen and felt in a way that allows for personal discovery you wouldn’t otherwise get in therapy that doesn’t incorporate ketamine.
Can patients expect an epiphany or a breakthrough?
In order for someone to have catharsis, they need access to both the intellectual memory and the emotional memory of what happened. That isn’t something that’s easy to access. We could tell a story of a car accident that happened ten years ago, but we’re not experiencing the fear that we had when it was happening. Getting that combination of intellectual awareness and emotional memory is a task in and of itself, but MDMA and ketamine can help in doing that. The third piece we need for catharsis is an empathic environment. We need to feel safe, and we need to feel like the person in front of us understands our experience.
What are the risks of taking ketamine?
Medically, the risks are extremely low. In every hospital in the country, ketamine is used as an analgesic for pain on a daily basis and for surgical procedures at a much higher dose.
I haven’t run into any negative consequences using ketamine myself or with my patients. The risks are similar to those of any consciousness-altering substance: If you bring up old trauma or old emotions or old memories in a setting where you’re not met with empathy, it can lead to you feeling worse than you did to begin with, until it’s worked through.
Most people who receive ketamine therapy are doing it via ketamine infusions. IV therapy has more risk involved, because you’re using much higher doses, and at most centers that provide this treatment there typically isn’t any psychological-support component to help you process the emotions or the trauma that might arise.
We see more risk with other psychedelics, like MDMA and psilocybin, just because they tend to be a really powerful experience even at low doses. Ketamine is much more subtle. With MDMA, people describe a rolling experience, where you get this flood of emotion and memories, and then you come down, and then you come back up, and down again, etc. But one ketamine session is like a single roll of MDMA—you typically get one transpersonal experience, and then you come down, and it’s quite subtle for the rest of the session. Overall, it’s just much less intense.
What can ketamine-facilitated therapy help treat?
Most of my patients suffer from anxiety, PTSD, depression, or bipolar disorder. Ketamine infusions can be immediately helpful with depression, in extreme cases where a patient presents with suicidal ideation. Studies have shown it acts in a similar manner to that of drugs like Prozac; monthly infusions are needed, or the depression comes back.
People who are experiencing physical symptoms from anxiety or chronic pain can potentially benefit from ketamine-facilitated therapy because of the psychological component of those issues.
We typically think of dissociation of the mind from the body as being a negative thing, especially as it relates to trauma and PTSD. Why is it helpful in this context?
Dissociation is a psychological defense mechanism the mind has, like the classic ones that you hear about—like using humor or projection. Dissociation is when you separate yourself from the reality of what’s happening right now.
We all do this. People who have trauma, usually as kids, often learn to cope with stress through dissociation. That tends to be very difficult for them because if you’re at work or with a lover or with friends and you dissociate, it can get in the way of your life. It’s really an unpleasant symptom or defense mechanism to have. But it’s not uncommon for people with PTSD or borderline personality or victims of sexual abuse to have dissociative symptoms.
Ketamine is a dissociative drug, especially at higher doses. Not a lot of research has been published, but those of us who have been using it with people with PTSD who dissociate are finding pretty good results with it. It’s different, though, because it’s a controlled dissociation; you’re with a practitioner whom you trust and you’re able to undergo a process of working through those traumas.
We don’t know how it works. One hypothesis I have is that our feelings come from our body: We know we’re anxious or we know we’re sad or we feel ashamed because our body sends us signals. They’re usually unpleasant, and that’s when we go to alcohol or some other behavior to dull the negative sensations and feel better in the short term.
Ketamine, however, dissociates the mind from the body. All of a sudden you can work through a problem—you can really look at yourself—without having all the negative feedback from your body. You’re looking at a situation or a memory without your body giving you unpleasant feedback that you’re ashamed, scared, or sad. But in your mind, you’re fully aware, you’re conscious, you’re present. You’re almost able to make changes to how you think and the way you look at the world while you’re in that state. As the ketamine comes down, people often feel differently—better—about a situation that’s been bothering them for a long time. The memory of the trauma is still there—it always will be—but the context has shifted.
Will Siu, MD, DPhil, completed medical and graduate school at UCLA and Oxford University, respectively, before training as a psychiatrist at Harvard Medical School. He was on the faculty at Harvard for two years prior to moving to New York City to further pursue his interests in psychedelic medicine as a practitioner and a public advocate. Siu has been trained by MAPS to provide MDMA-assisted therapy and has a private practice in Manhattan where he provides individual psychotherapy and ketamine-facilitated psychotherapy. He is also on the faculty at Columbia University where he conducts research using IV ketamine to treat heroin and cocaine additions.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.
Monday, January 22, 2018