Doing It Together: Ketamine-Assisted Psychotherapy in a Small Group

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A KETAMINE JOURNAL

Both women lay quietly on camping mattresses at opposite sides of my office. Eye masks blocked out the light while earphones played the same music for both of them: a tribal, evocative playlist curated for ketamine experiences. One had a stuffed animal resting beside her, the other wore fuzzy slippers. They had both taken sublingual ketamine and I could only wonder what was transpiring beneath the eye masks.

These patients had little in common—there was 20-year age gap and they came from very different backgrounds. In terms of both psychiatric and psychological issues, however, they shared a good deal. Both felt they should be doing “more” in life, that they were inferior to those who got more done in a day, who received more occupational accolades, or who just had good things come more easily. The older of the women, “Ms B,” struggled with motivation and had recently been let go from her part-time job, the first job she’d had in several years. Some days she spent in bed, and in the many years we have worked together, she has tried many different medications—at least 25—as well as transcranial magnetic stimulation. The younger woman, “Ms C,” had not had as many medication trials, but an unexpected insult—one that fed into her own negative beliefs about the lousy deal she had gotten in life—had led to a suicide attempt and a hospitalization. Both women worried constantly about what others thought of them and struggled with their self-esteem, even during times when they were doing well. These are themes that I often hear in psychotherapy from individuals who struggle with depression, and this was a thought pattern I hoped ketamine might help disrupt. The women had bonded quickly over their shared distress and their love of cats.

This was my first experience administering ketamine to more than 1 person. While I hoped to start doing consultative small groups, these were patients I knew well. I was following the advice Darrick May had given me at The Psychedelic Research and Training Institute (PRATI): go slowly and do not take on too much at once.

Because there were only 2 of them, I called it the “mini group.” To simulate what might happen with more people present, a cofacilitator was there and we had started with some get-to-know-you exercises. Because this was ketamine assisted psychotherapy, it was about more than just giving the medication. The first 2-hour session involved having the patients meet and prepare for the experience of trying ketamine.

“If you could have any superpower,” the cofacilitator asked, “what would it be?” She had retired from a career in human resources and was adept at running retreats and nonclinical groups. I hired her to assist for safety—I wanted a second person present in case I needed to attend to a medical issue—but these additional group skills were very helpful.

“I would like to know what other people are thinking,” Ms C offered. “I always assume people are thinking the worst about me, and perhaps if I knew, I might realize that people are not thinking about me at all.”

Ms B, the patient who had tried so many other treatments, announced she wanted a miracle: she wanted her depression to be gone, and her competence and motivation to be better.

I ask patients to make some changes in their life in 2 weeks before they come to the ketamine groups. I ask them to curtail the use of alcohol and cannabis, eliminate processed foods, and to exercise and meditate daily. A walk is good, a walk in nature is better. I want them to spend about an hour a day preparing an optimal physical and mental state for ketamine.

After using ketamine, there is a period of neuroplasticity, and I encourage patients to use the days that follow as a time to make changes in their thinking patterns and self-defeating habits. I ask everyone to write out a list of all the things they do not like about themselves. This list is for the patient’s eyes only; it not to share with me or the group. If anything is better at the end, I tell the ketamine patients, it is a win. We are not expecting 3 ketamine sessions to be curative. We are hoping to change negative patterns that fuel depression. “Look for a shift, not an earthquake,” I would tell patients. I was not expecting miracles and did not want to offer false hope.

“I can hope for a miracle,” Ms B stated, again.

“You can hope for a miracle,” I responded.

Before giving ketamine, I checked both women’s blood pressure and I asked them both to set an intention for the ketamine experience. I left the cuffs on their arms so I could check blood pressures 40 minutes after they took the ketamine. Sublingual ketamine does not taste good, and the patients held it in their mouths for 15 minutes, then spit out their saliva. Then both women placed on the eye masks, put on earphones, and rested for the next 75 minutes, along with their stuffed animals and fuzzy slippers.

The ketamine sessions proceeded without event, no one’s blood pressure increased and no one had a frightening experience. When it was over, the cofacilitator asked both participants to draw a picture of what they experienced. She explained that this was a way of accessing a different part of the brain than one would get with a verbal description. It was a part of the session that everyone enjoyed. Both women then talked about what happened. In the space of 3 hours, they both felt their moods had lifted.

The following day, I called both patients to check on them and ask if there were ways they could relate what happened in the ketamine experience to their lives. Both women worked on self-acceptance, one found solace in the thought that she might not end up alone, the other focused on the idea that her life was ‘enough,’ a word that came to her under the influence of ketamine. We met 2 more times for ketamine, and then for a final 2-hour integration session.

I had the patients fill out Beck Depression Inventories. Ms B started with a score of 28, moderately depressed, and after the third session her score of was half that—she still had mild depression. Ms C started with a score of 31, just over the cut-off for severely depressed, and ended with a score of 8, a score consistent with mild symptoms but not clinical depression. Over the course of the group, her family and friends commented that she was brighter and more even-keel.

“How did we do for a miracle?” I asked Ms B at the end.

“Not bad,” she answered with a smile.

For my first small group ketamine experience, everything had gone smoothly and the participants got the results they wanted. It almost felt too good to be true and I was eager to continue this work. In the final entry of this journal, I will let you know how both mini-group participants did in the months to come.

The views and practices expressed in these commentaries are solely those of the author and do not necessarily represent the position of Psychiatric Times or its editors.

Dr Miller is a clinical psychiatrist and writer in Baltimore. She is on the faculty at the Johns Hopkins School of Medicine.

Note: In these commentaries, Miller will discuss her experiences and thoughts as she explores issues associated with ketamine-assisted psychotherapy.