The document is an overview of ketamine-assisted psychotherapy, detailing its history, mechanisms, therapeutic applications, and treatment protocols. It covers treatment indications for various mental health conditions, the psychotherapeutic model employed, and potential risks and contraindications. The document highlights the importance of collaborative treatment planning and integration of experiences for effective patient outcomes.

1. Introduction to Ketamine-Assisted Psychotherapy
San Francisco Psychological Association May 30, 2020
COPYRIGHT 2020
POLARIS INSIGHT CENTER – SAN FRANCISCO
Gregory Wells, Ph.D. & Harvey Schwartz, Ph.D.

2. POLARIS INSIGHT CENTER
SAN FRANCISCO
Ketamine-Assisted Psychotherapy, Training & Consultation
4257 18th Street SF, CA 94114

4. KETAMINE

6. BACKGROUND and HISTORICAL PERSPECTIVES
1. History of Ketamine
2. History of Psychedelic-Assisted Psychotherapy and Psychedelic
Medicine
3. Diverse Models: Biological/Medical – Psychological –
Transpersonal/Shamanic
4. MDMA – Psilocybin - Ketamine
5. Influence & Legacy of the War on Drugs
6. Influences on the Development of the KAP protocol/model

7. Treatment Indications
◇ Treatment Resistant Depression
◇ Anxiety Disorders & OCD
◇ PTSD
◇ Addictions
◇ Psycho-spiritual growth process
and existential distress
◇ Pain Disorders
Contraindications
◇ Severe Personality Disorders
with caution
◇ Delusional Disorder
◇ Bipolar with caution
◇ Untreated HTN
◇ Cardiovascular Disease
◇ Kidney disease or impairment

8. Ketamine’s Signature (1)
• Rapid onset, Rapid metabolism & Excellent safety profile
• Dose-related access/flexibility for therapeutic process – Psycholytic &
Psychedelic
• Reduction/Elimination of external stimuli and sensations &
heightening of internal visual experience
• Preservation of the observer-self, observing-ego, witnessing-self
• Outside of bounded time and space – different levels and depth of
altered state experience

9. Ketamine’s Signature (2)
• Spaciousness of mind, Freedom of mind, Sense of movement and
music essential
• Reduction of verbal thinking and processing and connection to
symbolic realm of experience
• Reduction in negative, obsessive, and self-referential thinking
• Experience of surrender, formlessness, love, interconnectedness,
humility, awe, gratitude and union with Divine Love, Divine Mind
• NDE, OBE, Archetypal Experiences/Encounters
• Navigating the range of ecstatic to challenging experiences

10. Ketamine Assisted Psychotherapy
vs
Ketamine Treatment
Treatment room at Polaris Insight CenterTreatment room at IV infusion clinic

11. NEUROBIOLOGICAL
“BROAD STROKES”

12. Neurobiological Mechanisms of Action
• Increased Glutamate: Ketamine is an NMDA (N-methyl-D-aspartate)
glutamate receptor antagonist: transmission –prefrontal cortex
• “Master Switch:” Glutamate - most abundant and important excitatory
neurotransmitter, aka “Workhorse of the Brain”
• Glutamate Roles: Pain, Anxiety, Inflammation, Stress, Fear Conditioning,
Depression, Neurological/Psychological Resilience, Learning, Memory
• Changes in cell signaling, synaptic plasticity and strengthens neural
circuitry

13. Neurobiological Mechanisms of Action
• Reverses Neuronal Atrophy
• Supports Synaptogenesis & dendrite spine morphogenesis
• Strengthens synaptic connections – learning/memory consolidation
• Reduces brain activity in areas involved in rumination and self-monitoring
• Disrupts DNF (default mode network), creates hyper-connectivity
• Regulates downstream to other neurotransmitter systems

14. RISKS and SIDE EFFECTS
• Nausea and Vomiting
• Transient increase in BP and heart rate
• Dizziness, disorientation, blurred vision, headache, dry mouth
• Increase or decrease in energy (fatigue or restlessness) (rare)
• Neurotoxicity- only in chronic and high dose usage
• Potential for tolerance & abuse and dependence
• Urethral cystitis and bladder pain with chronic and long term use
• Non-compliance

15. KAP
Prescriber
Patient Therapist

16. Intake and Treatment
Planning
• Collaborative - Physician, Therapist, & Patient
• Review medical history, screen for contraindications and
determine candidacy
• Completion of assessment measures
• Treatment plan and dosing strategy is determined
collaboratively

17. Psychotherapeutic Model
• Emphasis on Set, Setting, Music, Interpersonal Connection
• Therapeutic relationship as primary container - physician
and medicine support the psychotherapy
• Preparation and Integration built into treatment plan
• Non-Ordinary States of Consciousness are held as crucial
for healing and seen as meaningful
• 3-hour sessions allow for plenty of time to process material

18. INTAKE
SCREENING
INTEGRATIONPREPARATION
ASSESSMENT
KAP SESSION
(set and setting)

19. Preventing Medical
Emergencies
• Patient blood pressure taken before sessions, but no
continual monitoring
• Physician or RN stay onsite during IM sessions for
minimum of 1 hour after injection
• Therapists BLS certified
• To date there have been zero medical emergencies

20. Treatment Approaches
Low Dose
◇ Empathogenic Experience - Trance-
like state
◇ Psycholytic Therapy
◇ Allows for ongoing communication
◇ Induces mild dissociation, mildly
anesthetic, yet present and relaxed
state
◇ Generally low-risk; low side effects
Moderate to High Dose
◇ Out of Body Experience (OBE)
◇ Near-Death Experience (NDE)
◇ Ego-Dissolving Transcendental experience
◇ Moderate to profound dissociative sedation,
may be similar to high dose classical
psychedelics
◇ Potential for side effects; not suitable for all
clients

21. Dosing Strategy
• All patients start with low dose. Allows for patient to gently and slowly
experience the ketamine space and allows therapist to monitor response.
Minimizes anxiety.
• Initial sessions:
• SL: 100-200mg
• IM: 0.4-0.8mg/kg
• Subsequent sessions:
• SL: 200-400mg
• IM: 0.8-1.8mg/kg

22. Sublingual Lozenges
• Office relationship with Koshland Compounding Pharmacy
• Introduces patients to KAP while minimizing medical
invasiveness
• Allows for at-home use in some patients
• Empowers patients in their own healing
• Can be used in conjunction with IM administration

23. Treatment Protocol for Lozenge Sessions
◇ Medical and Psychological Assessment and Intake Session
◇ 1-2 in office sessions with low-moderate dose lozenges
◇ Education and guidance to prepare for at-home low dose sessions
◇ 6 at-home low dose sessions over 2-week period
◇ Therapist contact after every at-home session
◇ Patient required to have own therapist for weekly sessions
◇ Maintenance phase: less frequent sessions and/or IM sessions

24. Intramuscular
Injection (IM)
• Dosage is determined via active collaboration between
physician, therapist, and patient
• Better tolerated by some patients
• Allows for more precise dosing and stacked/titrated dosing

25. Safety and Monitoring
• No automatic refills
• Patients are required to communicate with
therapist after every at-home session
• Regular office contact required and cases are
reviewed at monthly case conference
• Planned use of mood monitoring apps in future
• Ongoing use of assessment measures

26. CHALLENGES AND CONTRAINDICATIONS
Medical Contraindications
Psychological Contraindications
Insufficient preparation
Resistance to Integration
Resistance to letting go
Resistance to facing problems
Inadequate collaboration with
other providers

27. The Healing Potential
of
Non-Ordinary States of
Consciousness

28. Empathogenic
Psycholytic
Out of Body Experience
Trance
Perinatal Matrices
Near Death Experience
Ego Disssolution
Moderate Dose
High Dose
Low Dose

29. Preparation
• Medical and psychological effects of the
medicine are described and questions
addressed
• Encourage trust in inner healing intelligence
• Expectation management - not a magic bullet
• Importance of intention, set, setting, integration

30. Sacredness of the Journey

31. Activation of
and
Trust in
the
Inner
Healing
Intelligence

32. Experiential
Learning

33. Near-Death Experience (NDE)

34. “I have died. I now see myself walking out of my body
and now I am seeing a light tunnel in the sky , it is
exquisite, experiences from my life passing by..”
Re-entering her body she said “I never felt so
comfortable and embodied, I feel renewed energy,
motivation, and desire for living my life fully. I cannot
wait to leave the office and start living”.

35. Integration

36. 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

37. MAJOR GOALS of 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 worldview and social system
• Process traumatic memories & meanings and navigate spiritual
emergency
• Improved navigation of interpersonal challenges and intimacy

38. AREAS OF RESEARCH
• Depression & Anxiety
• PTSD
• Pain Management
• Substance Abuse Recovery, Relapse Prevention
• Mixed KAP with CBT and Mindfulness based practices
• End of Life Anxiety
• Neurological/Neuropsychological Resilience
• Wellbeing, Spiritual growth and Personality Transformation

39. Recent Research on Ketamine - Depression
Dore et al. (2019) J. Psychoactive Drugs: Clinical Outcome - Three Large Private
Practices Administering Ketamine-Assisted Psychotherapy. Dep, Anx, PTSD
- 235 patients from 3 private practices treating with similar KAP model. Mean
age 42.7 years, 85% college + educ; M/F equal; 1/3 prior experience
psychoactive medicines. #KAP Sessions 1-25. (NO CONTROL GROUP)
RESULTS: BDI and HAM Anx – Clinically significant improvements. Number of
session/treatment duration- correlated positively with greater improvements.
- Greater improvements in patients with severe symptom burden – higher
scores on measures, suicidality at intake and within past year, hx of
hospitalization, higher ACE scores. Increased age correlated with increased
improvement.
Side effects: Nausea office/home 13%/6% nausea; 6%/2% vomit; Agitation
1/3%

40. Recent Research on Ketamine - PTSD
1. O’Brien et al. (2019) Pharmaceuticals. Impact of Childhood Maltreatment on
IV Ketamine Outcomes for Adult Outpatients w TRD
Results: Higher load of clinical symptoms and background trauma associated
with better response to a single as well as repeated infusions compared to
those with lower symptom load and less trauma hx. Higher loads also
associated with higher remission rates.
2. Ross et al. (2019). Annals of Clin. Psychiatry. High-dose ketamine infusion for
the tx of PTSD in combat veterans. N=30; 6 infusions
Results: Sign improvement in scores on PTSD & Depr; no change in substance
use.

41. Proposed & Recent Research on Ketamine:
PTSD & End of Life Anxiety
• Veen et al. (2018): Curr Topics Behav Neurosci – Subcutaneous Dose Ketamine in PTSD-a
role for reconsolidation therapy. Targeting the process of reconsolidation to attenuate
fearful and traumatic memories. Ketamine embedded in a CBT exposure type
psychotherapeutic process. Proposal to use therapeutic window to activate memories,
disrupt and reconsolidate.
• Wolfson and Cole- Multi-site Hospice Study – 2 KAP sessions – end of life anxiety,
depression, and PTSD (Proposed). KTC Foundation
• Martial et al. (2019). Consciousness and Cognition – Of all the drugs evaluated for semantic
similarity, Ketamine ranked the highest in terms of providing a safe and reversible
experimental model for Near Death Experience (NDE) phenomenology; raises possibility
that NMDA antagonists with neuroprotective properties may be released in the proximity of
death.

42. POLARIS INSIGHT CENTER
KAP Day-Long Didactic Trainings
info@polarisinsight.com
6/11/20 or 6/13/20 - Introductory Module
6/20/20 - Intermediate Module
Advanced & Experiential Modules TBA

43. Polaris Insight Center
4257 18th St.
San Francisco, CA 94114
415.800.7083
polarisinsight.com
info@polarisinsight.com
greg@polarisinsight.com
harvey@polarisinsight.com
THANK YOU!!!