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Ketamine Psychedelic Psychotherapy

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Ketamine Psychedelic Psychotherapy KETAMINE PSYCHEDELIC PSYCHOTHERAPY EVGENY KRUPITSKY AND ELI KOLP INTRODUCTION Ketamine hydrochloride is a general anesthetic which has been used for noncon- ventional applications in substance abuse rehabilitation because of its psychedelic properties. This chapter summarizes the results of the research on KPP (ketamine psychedelic psychotherapy), principally with alcoholics and heroin addicts. Mechanisms underlying the effects of hallucinogen-assisted psychotherapy are addressed. Research illustrates how the temporary but effective anti-addictive benefits for a short period of time can be extended for longer periods of time to improve overall long-term adjustment and level of functioning. Ketamine hydrochloride, a prescription drug used for general anesthesia, induces profound psychedelic experiences when administered in sub-anesthetic .doses. Ketamine was originally synthesized in 1962 by the American chemist Calvin Stevens, and in 1966 Parke-Davis patented it for use as an anesthetic in humans. Ketamine became the most widely used anesthetic during the Vietnam War when American anesthesiologists and surgeons became familiar with the agent. In 1970, the U.S. Food and Drug Administration approved the use of ketamine with children, adults, and the elderly. Since that time, ketamine has been widely used in hospitals and for office procedures because of its large margin of safety, rapid onset, and short duration of action. More than 7,000 68 TREATTNG SUBSTANCE ABUSE published reports describe ketamine's high level of effectiveness and its biologi- cal safety (Shapiro et al. 1972; Reich and Silvay 1989; Ross and Fochtman 1995; Dachs and Innes 1997; Bauman et al. 1999; Ersek 2004). Clinical studies have detected no long-term impairment of behavior or personality functioning as a result of ketamine use (Siegal 1978). According to several reports, ketamine actually prevents brain damage from strokes, head trauma, heart attacks, epileptic seizures, low oxygen levels, and low blood-sugar levels (Weiss et al. 1986; Rothman et al. 1987; Shapira et al. 1994; Hirota and Lambert 1996). A rapid-acting, nonnarcotic, nonbarbiturate agent, ketamine has been termed a "dissociative" anesthetic, as it appears to disconnect the mind from the body, unlike the action of conventional anesthetics that basically extinguish conscious- ness. This dissociati ve action of ketamine creates what is described as "emer- gence phenomena," a nonordinary state of consciousness during which the individual's awareness and perception are dramatically changed and radically refocused.The patient completely loses contact with external reality and gets involved in a profound psychedelic experience. This experience may include (Khorramzadeh and Lofty 1976; Moore and Alltounian 1978; Weil and Rosen 1983; Lilly 1988; Krystal et al. 1994; Krupitsky and Grinenko 1997): • Feeling that one has left one's body (i.e., out-of-body experience); • Awareness of becoming a nonphysical being; • Emotionally intense visions; •Feelings of ego dissolution and loss of identity; • Visits to mythological realms of consciousness; •Reexperiencing the birth process; • Vivid dreams and memories of past incarnations; • Encounters with archetypal beings; • Experience of psychological death and rebirth of ego; •Feelings of cosmic unity with humanity, nature, the universe, and God. A profound psychedelic experience lasting from 45 minutes to an hour is induced by doses of ketamine about one-sixth to one-tenth of that typically used in surgery for general anesthesia. The following self-reports describe the details of the KPP experience that profoundly affected three selected patients: Patient A.S.: Sticky masses began to attack my body, to melt it. Fear invaded me. Every- thing around was in a whirl. One thing overlapped another. I felt the odor of alcohol. I felt excruciating aversion, fear, and presentiment of death. Bright objects replaced one another at a crazy speed, everything went round, and I went round, too. It seemed to me that I would never get out of this nightmare; that I was slowly and painfully dying; that I, my entire self, would melt in this black mass, but my brain would go on working. That I would feel, think, not live, but suffer. ...Some voice was talking about alcohol; I felt a strong aversion .... KET AMINE PSYCHEDELIC PSYCHOTHERAPY 69 Everything I saw resulted from my hopeless life, my alcoholism. It was as if the trash accumulated in me during years and years went out of me during an hour. I do not want it to repeat; I am afraid of this nightmare .... I would never forget it. ." Patient S.K.: I felt that my legs did not move, and my body started stretching and falling down at a crazy speed. My consciousness concentrated at one point and became a part of the scene. I was flying to infinity along something like channels that interlaced and joined one another (everything was brightly colored: orange, red). Gradually, this crazy dance grew slower. I found myself in some closed space. At that moment an unconscious fear invaded me. Fear that I would never get out of this state-the state of being a part of something and not myself. The space where I was started filling with solid foam. I was cornered. At the last moment, when I saw that I couldn't get away, that the space I occupied was the only free spot, I heard something splash and felt myself free. Everything around became understandable (I thought that it was impossible to live the way I had lived). My family came distinctly to my mind .... Now it was as if my conscious- ness was over the things that were under me. Everything below looked like some brown layers: as if a clot of brown dough scattered in the air and came down to the earth and covered it all over. It seemed to be my past life. Again, a strong fear overwhelmed me as I was pulled to this brown mess. All my self rose against it. I deeply desired to live, to live as everybody else, and never see this nightmare again. And my desire won. At this point, I felt as if I opened my eyes and regained my sight. I saw a window, a green tree and the blue sky .. " Patient V.K.: As soon as I had been brought to the state of unconsciousness, I started slid- ing in a curve of the vertical plane. The latter was distinct and represented a blue line against the clearly visible and illuminated background. The thought: some- where there is a point which is important for you, which you should not miss, since it is a matter of life or death. I slid for a quite a long time, but I never met this point. Abruptly I found myself in a cave on the top of a high granite rock .... The rock rose high above the ocean that exactly resembled the thinking ocean of (Stanislaus) Lem's 'Solaris.' The ocean was brownish-crimson, swirling, and looked like the upper parts of cumulus clouds, as seen from an airplane before the sunset. The cave had an entry which without any reason seemed black. The ocean was several hundred meters below the cave, and I could distinctly imagine that sooner or later I would fall down and it would swallow me up. I didn't feel my body, but in the cave some ellipse-shaped, orange concentrate of thoughts, my thoughts, was pulsating. The thoughts were: the universe is infinite in space and time; we are all mortal; the space, the ocean will always be, but thoughts will die and nonexistence will come .... I felt hopeless and was surprised only at one thing: why the thought to live persists, to live endlessly. Several scenes of my life 70 TREATINGSUBSTANCE ABUSE passed before my eyes. They were from my childhood and youth, everything in sad, reddish-brown colors. Several times the thought, but not the body, appeared at the exit ofthe cave and I could understand that I was about to fall down into the ocean, but I would not fall down and again would return into the cave.And again hopelessness and the sense of doom .... All this went on for a very long time .... Gradually, I began to come back to reality ... .It was not a dream and I didn't want to sleep; it was simply a desire to lie calmly. I was thinking of my experi- ence and gloomily analyzing it. I also thought about the questions I had been asked during the procedure .... In my opinion, I had heard everything, about alcohol, the attitude towards it, its consequences and about 'the finale' and my feelings ....My general condition: perfect physical state, strangely depressed psychological state (without any reason), a desire to somehow analyze my past life, some dull ache at the thought about past years, and some sharpened homesickness .... The attitude towards alcohol or anything similar: fear, a vague fear of everything that could disturb my distinct and clear consciousness and return it to something like what I had previously experienced. Be it some drink or injection or pills, it made no difference. If only the sober state were not disturbed, not even a little .... In addition to the transpersonal experience, ketamine also often induces a psychodynamic experience, a form of life review related to the patient's history and maladjustive patterns, which are then presented in symbolic form in the patient's visionary experience. Because of these powerful mind-altering effects, ketamine belongs to the class of psychopharmacological compounds known as psychedelics. The majority of psychedelic compounds, however, are illegal to use in the United States for therapeutic applications. In contrast, ketamine is not on Schedule I and is readily available to physicians as a legal anesthetic under the U.S. Controlled Substances Act of 1970. It can also be lawfully administered "off-label" in psychiatric treatment as an adjunct to psychotherapy, when admin- istered by a licensed physician.
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