Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture

1. Ketamine Assisted
Psychotherapy, (KAP),
Essential Concepts and Steps
Dr. Ahmed Albehairy, M.D
Psychiatry Consultant
Armed Forces Psychiatry Care Center, El-Taif, KSA

2. Ketamine – chemical
structure
- A chiral phencyclidine derivatives introduced in the
1956.
- C13H16ClNO
- Dissociative anesthesia.
- Racemic mixture:
• Esketamine (S(+)-isomer)
• Arketamine (R(−)-isomer)

3. History of ketamine
- ketamine was first reported to have antidepressant properties in 2000, (R M Berman
et.al ).
- In the past two decades, ketamine has shown promise as a novel treatment
modality for TRD.

4. History of Ketamine Assisted Psychotherapy:
• Roquet discovered that subanesthetic doses of the drug occasioned
mental states that could be combined with psychoanalytical
techniques and indigenous healing practices in an approach he called
“psychosynthesis” (Yensen, 1973; Wolfson, 2014).
• By Wolfson, & Hartelines, 2016, ketamine assisted psychotherapy has
developed as a new and ground breaking psychotherapy.

5. Essential Concepts of KAP :
Ketamine ( in subanaethetic dose ) is used to create a state of altered
consciousness ( dissociation vs. trance), with adjunctive psychotherapy
can help patients break through mental blocks , integrate intrapersonal
parts ( ego, Id, values, conflicts, self concept, perception, expectation,
& motivations , and gain insight and explore thoughts, emotion, and
intentions. These lead to change and transformation with healing and
growth.

6. Essential Concepts of KAP :
• Frame works of KAP:
1- Experience oriented ,
- low-dose “psycholytic therapy,” in which ongoing psychotherapy
coincides with ketamine administration, making use of acute drug
effects that are thought to facilitate the quality of therapy.
- High dose “psychedelic therapy,” involving significant preparation
before and integration after a limited number of drug sessions.
2- Plasticity oriented ,
wherein psychotherapy is delivered after the period of acute drug
effects but within “critical periods” of neural adaptation that are
thought to facilitate the uptake and efficacy of behavioral
interventions.

7. The Psychoneurobiology of Ketamine :Psychotherapeutic effect of
Ketamine:
• Disruption of circular patterns of thinking and rumination (spaciousness of
mind).
• Reducing negativity, negative narcissism and self-obsession.
• Remodeling/Reconfiguring of the sense of self.
• Increasing cognitive and emotional flexibility.
• Developing discriminating wisdom and discernment.
• Reworking traumas and putting them in the past.
• Relaxing habitual hypervigilance.
• Enhancing capacity for meditative mindfulness.
• Enhancing creativity and problem solving.
• Developing respect for one’s own mental capacities.
• Cultivating greater trust in (and compassion for) self and others.
• Accepting impermanence and decreasing existential distress/anxiety.

9. KAP Effectiveness:
• KAP produced sustained reductions in anxiety, depression, and PTSD,
with symptom improvement lasting well beyond the duration of
dosing sessions. These effects extended to as much as 5 months after
the last KAP session.
Ketamine-assisted psychotherapy provides lasting and effective results in the treatment of depression, anxiety and post traumatic stress disorder at 3 and 6
months: Findings from a large single-arm retrospective effectiveness :triaRyan Yermus MD, Michael Verbora MBA, MD, Sidney Kennedy MD, Robert McMaster MD,
et,al. ,this version posted April 18, 2023.

10. Ketamine assisted Psychotherapy
( Intrapersonal Psychotherapy),
components:
• Client centered.
• Open questioning .
• Guiding, help only and not leader nor interpreting. (CBT, ACT).
• Dissolve defense mechanisms ( psychoanalytic therapy).
• Facilitate mindfulness ( DBT , Integration ,and Transformation).
• Psychedelic journey ( NDE, OBE, relate to cosmos and intrapersonal parts,
spiritual intelligence ).
• Parts work ( IFP, self , manager , firefighter , exiles).
• Somatic intervention( sensory motor psychotherapy).
• Inner healing intelligence ( the knowledge and power within oneself to move
towards wholeness and wellbeing).

11. Over View of KAP Protocol

12. Over View of KAP Protocol:
• Screening .
• Intake.
• Assessment .
• Preparation.
• Set and setting.
• integration.

13. Screening, Assessment
• Psychosocial- spiritual history .
• Diagnosis ( psychiatry and physical conditions ).
• Current social support.
• Psychometric scales .

14. Preparation:
• Screening tests: Liver function tests, urine pregnancy, urine drug
Screen.
• Vital signs: blood pressure not more than 160/100.
Exact height and exact weight.
• Consent form: Signed and witnessed. Psychoeducation about
ketamine and expectation management.

15. Preparation: :
- Intent.
- Body and diet.
- Driving arrangement.
- Moderate expectation, to learn more than to control.
- Inner healing intelligence.
- Eyeshades.
- Deep silent reflection.
- Exploration of experience.
- Narratives.
- Music.
- Side effect: ( OBE, NDE, SLEEP)

16. Intake:
- Sub-anaesthetics : 0.2 – 0.8 mg/kg I.V or equivalent doses of other
modes of administration . ( INTRAMUSCULAR , INTRANASAL ,
LOZENGS).
- Booster ( divided ) dose can be given after 30 minutes of the
session’ beginning.

17. Set and Settings:

18. Set and Settings:
- Each session is 3 hrs, ( ½ hr. for ketamine intake effect, 1.5hr for
questioning and experience exploration (journey), last 1 hr. for
integration).
- At least 3 sessions of KAP are needed.
- Most of the patients needs 4 to 6 sessions . Ist 2 sessions for
preparation to avoid bad journey.

19. Integration:
• The therapist helps the patient integrate the different parts of their
psyche into cohesive whole. This process may involve developing
new coping strategies, ways , and vision of dealing with difficult
emotion.

20. Major goals of KAP integration:
• Safety/stabilization: Smooth re-entry, prevention,
ongoing monitoring.
• Attachment: Relationship continuity and repair & deepen collaboration.
• Enhanced self-monitoring: Observing ego, neutrality, disentanglement.
• Debriefing: Emotional processing, meaning- making, releasing, grieving.
• Resolving: Pathogenic beliefs and conflicts among parts of the self.
• Durability: Accrual of benefit & consolidation of gains.

21. Major goals of KAP integration:
• Dedicated application of new found wisdom; support behavior changes.
• Understanding challenging experiences: psychological & archetypal/
spiritual.
• Effective use of transference and countertransference Experience.
• Coping with changes in identity and world view and social system.
• Process traumatic memories & meanings, and navigate spiritual emergency.
• Improved navigation of interpersonal challenges and intimacy.

22. Transformation , end result
A change in one’s core conceptual and even physical structure that
interrupts the prior sense of self and world view and induces an
altered, at least partially different, sense of self and world view
immediately and/or over time with some degree of persistence.
Transformation is a reboot of our operating system with at least some
new programming and sometimes even a change from system 1.0 to
2.0.

23. REFERENCES :
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• 2.Pollan,M.(2019) Howtochangeyourmind:Whatthenewscienceofpsychedelicsteachesusaboutconsciousness,dying,addiction,depression,and
transcendence. PenguinRandomHouse.
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24. THANK YOU