Things to Worry About


Getting ready to do ketamine-assisted psychotherapy requires a lot of preparation.




Like most people, I approach new things with caution. My default is to come up with reasons not to try something completely new, so adding ketamine-assisted psychotherapy (KAP) to the treatments I offer does not come easily. The tools of mainstream psychiatry—medications, psychotherapy, electroconvulsive therapy, transcranial magnetic stimulation—help many individuals, yet they do not help everyone, and for some, they do not help enough.

KAP does not fit into the landscape of conventional psychiatry. For those who feel psychiatrists should only offer treatments that are on the solid ground of evidence-based medicine, this terrain shakes a bit.

I hope there will be something to be gleaned from my experiences, but please do not take them as scientific studies, but rather as the anecdotes they are. Anecdotes do 1 of 2 things for science:

  1. They may include serendipitous findings that steer us to do the studies that make for evidence-based medicine.
  2. Or they mislead us to fruitless paths.

Psychedelic medicine is the cutting-edge in psychiatry, and I like staying current at a time when I might otherwise become obsolete. Many clinicians who offer KAP are ardent about its benefits, and I am not. My plan is to try it, and if it helps people, I will continue. If does not help, I will stop. I made up my mind, plotted a path, and did what I do when I worry: made lists.

My first set of worries was mostly about the fear of harming people. Is ketamine safe, and if it is, for whom? My lists included books and articles to read, people to talk to, and knowledge to obtain. Might I hurt someone? What was the liability here?

A colleague insisted I should update my Basic Cardiac Life Support (BCLS) certification, and I took a course at the local Red Cross. I did this even though I heard no stories of fatalities or CPR being done during ketamine treatment. I debated whether I needed an automated external defibrillator (AED) in my office and asked others who use ketamine. Some did have an AED—no one had ever used it or even heard of anyone who had.

Most ketamine, I discovered, is either given by a psychotherapist—often a social worker—with no medical personnel onsite, or taken by patients at home (settings that surely do not have AEDs).

I spoke with my malpractice provider and explained that I intended to remain in the room with the patients. I could be liable, but they were hearing from doctors who prescribed ketamine for patients to take with their therapists. This was, according to the risk management person I spoke with, “the right way to do it.”

As I pressed, I learned they had had no litigation related to ketamine. My malpractice would cover KAP so long as I only used it to treat psychiatric conditions. Individuals use ketamine for spiritual awakening, to facilitate relationship issues, and to train to do KAP. My door would be closed to those looking for enlightenment and open to those looking for symptom relief.

I had a blood pressure cuff. I bought enough to have 1 for each group participant. I also bought pulse oximeters and a scale that I kept set to kilograms as well as clonidine and ondansetron to have on hand. As time has passed, I have changed the pulse oximeters to ones that beep if a patient’s heart rate or oxygen saturation moves out of a certain range, and I have added metoprolol to my medication stock.

People get nervous before ketamine, and for some, this means that their blood pressure rises to the high normal range. I decided it would be safe to pre-treat anyone who is tachycardic or has blood pressure on the high end of the normal range, just to be sure that they did not get anywhere near “too high” after ketamine administration.

I hoped to offer ketamine to groups of 3 to 4 patients at a time. My thinking included the idea that individuals with psychiatric disorders can be very isolated and group therapy can be helpful, and that ketamine experiences are often described with words such as “unifying” and “transpersonal.” Shouldn’t such experiences be shared with others? These sessions also take time, and the logistical realities are that more individuals can have ketamine in a group.

Once I decided to administer ketamine in groups, I needed a protocol, and there no set protocols for KAP. I saw that a group in Fort Collins was offering 5 session groups, with 3 ketamine experiences, and that sounded like a model I could manage.

I worried about running ketamine groups as a single clinician and decided it would be good to have someone else in the room. I started to look for a therapist with a flexible schedule who might want to join me. I was meeting with a friend one day who had recently retired from working in human resources, who has a PhD in psychology, and whose warm and gentle manner I find calming. Barb was interested in co-facilitating ketamine groups with me, and I was excited to have someone share my enthusiasm for this endeavor.

My next set of lists included an assortment of objects: foldup mattresses, eye shades, a sound system with 4 sets of earphones that could connect to KAP music playlists from my Spotify account, mints and ginger lozenges, throw blankets and pillows, clipboards for notetaking, information and consent forms, and instruction sheets with a timeline leading up to the day of ketamine administration.

I found a local pharmacy that could compound sublingual troches for my patients. Although my original plan was to keep the ketamine in my office, the FDA rules around storing a controlled substance were more than I wanted to take on at first. The patients would pick up enough ketamine for the 3 sessions, prescribed with instructions to take only with physician supervision. If any ketamine was left at the end of the group, we would dissolve and discard the remainder.

From there, the next worry took over. I assumed there would be a demand for KAP, and I was not looking for individuals who were self-referred in search of spiritual enlightenment or mind expansion, or who wanted to avoid psychiatric care. I was also not looking to attract new patients for ongoing care, or to build a practice of individuals in search of an addictive agent.

I wanted this to exist as a way for other psychiatrists to have their patients try a ketamine group when conventional care had failed. It would not come with the promise of a cure. Instead, I wanted to provide a transformational and healing experience that could point individuals in a new direction. What if I built it and no one came?

Finally, while I was worrying anyway, I discovered that onsite ketamine training courses generally include an optional experiential component. This is true of the PRATI course I registered for, and in fact, the experience of both taking ketamine and serving as a guide for others are key parts of the educational experience. I have never experimented with recreational drugs (margaritas aside) and found the idea both very appealing and very nerve-wracking. So, I was going to learn to treat people with ketamine, and I would also be taking it.

My worries about trying ketamine are enough for their own journal entry.

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.

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