Module 1: Introduction to Ketamine Assisted Psychotherapy Harvey Schwartz, PhD & Veronika Gold, LMFT & Eric Sienknecht, PsyD

1. POLARIS INSIGHT
CENTER
SAN FRANCISCO
Ketamine-Assisted
Psychotherapy, Training &
Consultation
www.polarisinsight.com

2. Introduction to Ketamine-Assisted Psychotherapy
POLARIS INSIGHT CENTER – SAN FRANCISCO
.
BACKGROUND AND FUNDAMENTALS
Harvey Schwartz PhD, Veronika Gold LMFT,
Eric Sienknecht PsyD, Robert Voloshin DO

3. Eight Pillars of becoming a ketamine
assisted therapist
Personal Therapy
and Personal
Work with NOSC
Self-Paced
Learning
Live Presentation
and Q&A
Video/Live
Observation
(e.g., shadowing)
Non-Medicine
Practice
Supervised
Practice
(co-therapy)
Intensive
Supervision
(apprenticeship)
Ongoing
Consultation
(peer or
professional)

6. Paradigms
and Types of
Ketamine
Treatment
(Bennett, 2016)
Medical - IV Ketamine Treatment,
Intranasal, Sublingual
Psychological - Ketamine Treatment
with Integration Sessions or
Therapy after Ketamine Treatment
- Ketamine Assisted Psychotherapy
Transpersonal - Ketamine Assisted Psychotherapy

7. Ketamine Assisted Psychotherapy
vs
Ketamine Treatment
Treatment room at Polaris Insight Center
Treatment room at IV infusion clinic

8. Ethical
Considerations
for Training
of all Ketamine
Providers
 Potential of Psychedelic Experience (OBE, NDE)
 Regressed States - Suggestibility
 Abreactions
 Sensitivity to Dosing
 Vulnerability and Potential Enhancement of Trust
 Porosity (heightened sensitivity to set and setting)
 Kriya Published Ketamine Ethical Guidelines
Journal of Psychedelic Psychiatry (Vol 2, Issue 4, Dec
2020, pgs 19-23)

9. KAP
Prescriber
Patient Therapist

10. 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

11. KETAMINE

13. Salvador Roquet
introduced ketamine
to Maryland
Researchers
Stanley Krippner’s
observations at
Salvador Roquet’s
Psychiatric Clinic in
Mexico in 1971
• “As his patients began to feel the effects of the psychedelic
substances, Salvador’s staff projected a violent film, ‘The
Dirty Dozen,’ on one wall of the room, and an erotic movie
on the other wall. Salvador told us that his goal was to
assure his patients that the expression of both their
aggressive and sexual impulses was acceptable in this
milieu.”
• “The sensory overload show users slides, movies, three
stereo sound systems, and colored floodlights which flash
intermittently. The elements included in the slides and films
are as varied as possible. Within what seems a confused
barrage of unrelated images and sounds, there is a main
theme: life. Among the themes found useful, are death, birth,
sexuality, religion, and childhood.”
• “There were some 20 patients seated on the carpet or
cushions. Some arose and began to dance. Others cried or
sobbed, turning to each other for support and consolation as
they revealed intimate details about their life conflicts and
traumas. Salvador moved among his patients, orchestrating
their experiences and deftly forming spontaneous small
groups of patients with similar issues.”

14. John C. Lilly, MD, and Marcia Moore

15. Dissociative
“side-effect” is
KEY
• Carlos Zarate’s group at NIH in 2015
(Luckenbaugh et al, 2014) “Do the
dissociative side effects of ketamine
mediate its antidepressant effects?”
• 108 TRD inpatients received single
infusion of ketamine
• Level of dissociation at 40-minutes of
experience was significantly
associated with reduction in
depression immediately following the
treatment and at 7-day follow-up

16. FULL DISSOCIATION THE “K-HOLE”

17. Ketamine’s Signature 1/2
• Rapid onset, Rapid metabolism & Excellent safety profile
• Reduction/Elimination of external stimuli and sensations &
heightening of internal visual experience; connection to symbolic
realm of experience
• Preservation of the observer – witness consciousness
• Reduction in negative, obsessive, and self-referential thinking
• Spaciousness of mind, Freedom of mind, Sense of movement

18. Ketamine’s Signature 2/2
• Experience of surrender, formlessness, love, interconnectedness,
humility, awe, gratitude and union with Divine Love, Divine Mind
• Access to experiences outside of conventional time and
space – NDE, OBE, Archetypal Experiences/Encounters, etc.…
• Navigating the range of ecstatic to challenging experiences
• Dose-related flexibility for therapeutic process – Psycholytic &
Psychedelic

19. NEUROBIOLOGICAL
“BROAD STROKES”
This Photo by Unknown Author is licensed under CC BY-SA

20. BROAD
STROKES:
PSYCHEDELICS
 New paradigm: drug facilitated psychotherapy/successful
research (safety, retention, outcome)
 Transdiagnostic – works with broad spectrum (“internalizing
disorders”; “pivotal mental state”)
 Prophylactic potential (prevention and repair)
 Neuroplasticity: from defensive canalization to cognitive-
emotional flexibility
 Disrupting Entrenched Systems and Rebooting/Resetting brain,
mind & personality
 Default Mode Network Interference (Identity, beliefs,
ruminations)
 The psychedelic experience and therapeutic window
 Core Paradox: dysregulation, benevolent disruption; breakdown
to breakthrough

22. Neurobiological Mechanisms of Action 1/2
• Increased Glutamate Ketamine is an NMDA 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

23. Neurobiological Mechanisms of Action 2/2
• 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 DMN (default mode network), creates hyper-connectivity
• Regulates downstream to other neurotransmitter systems
• Increase pyramid cells (the movers and shakers of the CNS)

24. The Effects of Ketamine on Symptoms of Depression
(Typical and Atypical Sx)
(Park et al 2020)
Typical Symptoms of Depression
(most significant changes)
Pessimistic Thoughts
 Inability to Feel
Lassitude
Reported Sadness
Atypical Symptoms of Depression
(most significant changes)
Social withdrawal
Fatiguability
Carbohydrate craving
Day 1 after Tx – Typical Symptom Relief higher than Atypical
By Day 3 after Tx – Equivalent effects on both
Possible divergent mechanisms for both

25. The Effects of Ketamine on Symptoms of Depression
(Typical and Atypical Sx)
(Park et al 2020)
Typical Symptoms of Depression
(most significant changes)
Pessimistic Thoughts
 Inability to Feel
Lassitude
Reported Sadness
Atypical Symptoms of
Depression (most significant
changes)
Social withdrawal
Fatiguability
Carbohydrate craving
Day 1 after Tx – Typical Symptom Relief higher than Atypical
By Day 3 after Tx – Equivalent effects on both
Possible divergent mechanisms for both
FROM NEURO TO PSYCHO:
The Psychoneurobiology 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

26. General Effects of
NOSC and
Psychedelics-
Oneness and
Selflessness
• Transient Hypofrontality
• Transient Hyperconnectivity
• Default Mode Network
Interruption
• Cortico-Thalamic Gating
• Neuroplasticity
• Integrated Models of:
Neuroanatomy-Neurochemistry-
Neuroelectricity

27. BREAK

28. This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-SA

29. THEWARS on DRUGS
1500-1700s
Conquistadors/Catholic
Missionaries War on Native
Populations' spiritual
practices (with entheogens)
1930's
Harry Anslinger - Fed Bureau
of Narcotics- Prohibition,
Criminalization, Racism
1960-1970
s-1970s Nixon's "War on
Drugs" - Scheduling
psychedelics; Anti-War
movement; Black Liberation
Movement
1980s - 2000
Reaganism: "Just Say No”
Scheduling of MDMA; Iran-
Contra
2000-present
The psychedelic renaissance
period
Clinical Trials
Decriminalization

30. •War on Drugs/Disinformation vs. Psychedelic Research/Practice
•Big Pharma vs. Little Pharma vs non-profit (Healthcare, Insurance)
•Ketamine World: Anesthesiology vs. Psychiatry (K infusion vs. KAP)
•Psychedelic World: Underground vs. Credentialed Professionals
•Biological- Psychological - Shamanic/Transpersonal Models
•Medical vs. Nonmedical Practitioners vs. Multi-modal tx protocols
•Addiction Issue: safety, efficacy, prevention/management

31. • Neurotoxicity Issue - safety vs. risk management vs. disinformation
• Goals of Tx: Symptom relief, personality/character change, life quality
• Training psychedelic therapists with/without direct experience?
• Drug regulation/restriction criminalization, incarceration- versus drug
education and personal freedom, consciousness freedom
• Essence of Healing? - molecule vs. relationship vs. both
• Changed Role of the Therapist and Role of the Patient
• Relevance of standard clinical measurements for transformational Tx

32. • Improved scores but quality of life remains largely unchanged
• The scientific method, and what falls outside of that method
• Narrow Empiricism
• When the measurable drives away the significant (Demott)
• Science vs. Scientism
• If it cannot be measured then it doesn’t exist?
• Interpretation of data from differing philosophical/clinical positions
• Does getting worse in a healing process mean unsuccessful outcome?
• Measures used emphasizing psychopathology versus “positive
psychology”
WHAT ARE WE EVALUATING?
WHAT IS SUCCESSFUL Tx OUTCOME?

33. •Role and value of pleasure, awe, wonder in healing
•Role, value and risks of physical touch and contact
•Significance of dissociative, mystical, transpersonal experiences in tx
•Racial, ethnic, economic divisions regarding ACCESS and availability
•Cultural appropriation vs. Cultural honoring in treatment protocols
•The worried well vs, the Psychologically distressed - is it kosher?
•To manualize treatment or not to manualize
• Decolonizing Psychedelics: Beyond extraction, piracy, exploitation and bio/spiritual
“prospecting”
•Psychedelic Naivete, Psychedelic Narcissism, Psychedelic Fascism, Psychedelic Homophobia

34. INTAKE
SCREENING
INTEGRATION
assessment
PREPARATION
KAP SESSION
(set and setting)
OVERVIEW OF KAP PROTOCOL

35. Psychological
Intake and
Screening
• Developmental/Trauma Hx
• Psych Treatment Hx, Dxs, risks
• Hx SA, Use of psychedelics
• Religious/Spiritual Hx
• Current support system
• Psychoeducation around KAP
• Address questions about KAP
and Consent Forms
• ROIs for outside providers
• Prep for first KAP session, if time

36. Psychological
Intake and
Screening
• Psychological Testing:
• PHQ-9
• GAD-7
• PCL-5
• ACE
• BDI-II
• Change of State (after
treatment)
• Resiliency
• MEQ, EDI (after treatment)

37. 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
like high dose classical psychedelics
◇ Potential for side effects; not suitable for all clients

38. IM Dose
Response
Curve
(Lilly)

39. Depression
Mental illness (organic, hereditary,
due to accident)
Physical Illness
Inflammatory Process
Endocrine and Hormone Disorders
Substance Misuse/Abuse/Addiction
Stress
Grief and Loss
Trauma
Pain
Anger/Rage (suppressed)
Environmental Issues
Lifestyle Issues
Interpersonal Style and Personality
Disorders
Transpersonal and Collective Pain
and Trauma
Political, Racial, Immigration Stress
and Trauma
Economic Distress and Chronic
Poverty

40. Characteristics of
Positive Responders
Based on Feedback and inspired by Raquel Bennett

41. CHALLENGES Raquel Bennett, PsyD
Not having a rigorous and comprehensive intake
process for prospective ketamine patients
Not adequately covering all the risks and benefits of
ketamine and KAP in the initial screening, intake and
prep sessions
Not providing adequate psychological preparation for
ketamine treatment
Not providing adequate psychological support during
ketamine administration
Not providing adequate follow-up care to ketamine
patients
Inadequate training, supervision and consultation
Medical malpractice

42. CHALLENGES AND CONTRAINDICATIONS
 Medical Contraindications
 Psychological Contraindications
 Not sufficient preparation
 Resistance to Integration
 Not wanting to let go
 Not wanting to face the problems
 Not adequate collaboration with
other providers of the patient

43. Medical Intake
and Screening
• Collaborative - Physician,
Therapist, & Patient
• Review medical history and
medications and screen for
contraindications
• Education about safety of
ketamine and drug
interactions
• Answer patient’s questions

44. Contraindications and potential misuse
The following conditions are orange/red flags:
 Pregnant women and nursing mothers (though Wolfson’s
recent study on lactation indicated flexibility in 24 hours or
less)
 Poorly controlled or untreated hypertension and other
cardiovascular problem
 Poorly controlled or untreated hyperthyroidism
 Acute Mania/Hypomania
 History of psychosis or schizophrenia
 Allergy to ketamine or past addiction to ketamine
 Recent Traumatic Brain Injury (12 months or less)
 Severe Obstructive Sleep Apnea or Respiratory Disease
 Obesity >300LB
 An ongoing substance abuse disorder or addiction
 History of bladder or cystitis

45. Sublingual Lozenges
and Troches
• Office relationship with Koshland 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

46. INTRAMUSCULAR
• Active collaboration between physician,
therapist, and patient
• Better tolerated by some patients – less
side effects
• Allows for more precise dosing and
stacked dosing

47. Dosing Strategy
• Low dose IM: 0.25 mg – 0.5 mg/kg
• Moderate dose IM: 0.5 mg – 1.2 mg/kg
• High dose: 1.2 mg IM – 2.0 mg/kg
• Lozenges 50mg, 100mg, 200mg
• Dosing sublingual: 50mg - 300mg

48. Bioavailability of
Ketamine
• Oral 14% - 15%
• Sublingual 25%-50%
• Intramuscular 93%-95%
• Intravenous 97%-98%

49. Ketamine
Formulation
Dose
Equivalency

50. Medication
Interactions
Benzodiazepines
Opiates
Alcohol
Lamotrigine
Calcium channel blockers

51. KETAMINE 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

52. Addiction
• Ketamine can be
psychologically addictive
• No evidence of physical
dependence, but withdrawal
is possible

53. Safety and Monitoring
• Logging medication
• Medication cabinet
• CURES (CA)
• In-office visit required for medical
evaluation
• Emergency Medical Response Plan
• Rescue medications

54. Risk management
Patients required to
communicate with
therapist after every at-
home session
No automatic refills
Prescribing limited
number of lozenges for
trial period
Lozenges - difficult to
abuse

55.  Healing Potential
 Transformative Potential
 Evolutionary Potential
 Heuristic Potential
Art by Jake Kobrin
NON-ORDINARY STATES OF CONSCIOUSNESS
HOLOTROPIC STATES
STATES OF EXPANDED CONSCIOUSNESS
STATES OF ALTERED CONSCIOUSNESS

56. THE HEALING
POTENTIAL OF
NON-ORDINARY
STATES OF
CONSCIOUSNESS

57. Stanislav Grof
 Biographical
 Perinatal
 Collective/Mythological
 Archetypal
 Mystical/Causal
- Based on work with LSD and
other holotropic states
Typology of
NOSC
Chris Bache
 Personal/Biographical
 Collective
 Archetypal
 Oneness/Causal Realm
 Diamond Luminosity
-Based on work with LSD
Eli Kolp
 Empathogenic State
 Out of Body Experience
 Near to Death Experience
 Ego Dissolution
Transformational
Experience
- Based on work with Ketamine

58. NEAR DEATH EXPERIENCES

59. Cosmic Consciousness

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

61. Activation of
and
Trust in
the
Inner
Healing
Intelligence

62. Experiential
Learning

63. Set & Setting

64. Mind-Set

65. Flight Instructions
Make them your own!

66. Polaris Insight Center

68. Ketamine Music

69. Ketamine Music Principles
• Considerations in selection of tracks for playlist:
• Ambient music, changing styles, “textures”
• Match the arc of the medicine effects
• Unfamiliar music is better!
• Lyrics can be distracting
• Three factors to consider in assessing the influence of the music
on Pt’s experience (Kaelen et al, 2017, The Hidden Therapist):
• The type of music (like/dislike)
• Match to their process (resonance/lack of resonance)
• The material that the music is eliciting (openness/resistance)
• Explore resistance but be flexible to adjusting/changing music
as needed

71. Integration

72. MAJOR GOALS
OF KAP
INTEGRATION
(1)
● 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

73. MAJOR GOALS
of
INTEGRATION
(2)
• 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

74. Future
Training
Opportunities
• Intermediate KAP
Webinars
• Advanced KAP Webinar for
practicing providers
• Module 5 - practice KAP
• Consultation Group
• Polaris Intensive KAP
Retreats

75. Polaris Insight Center
4257 18th St.
San Francisco, CA 94114
415.800.7083
polarisinsight.com
info@polarisinsight.com
harvey@polarisinsight.com
eric@polarisinsight.com
veronika@polarisinsight.com
THANK YOU