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A Guide to Guiding

Perhaps one of the worlds most famous guides. Tenzing Norgay, guide to Mt. Everest, pictured with client Sir Edmund Hillary,

As a psychiatrist and therapist I'm used to treating patients, not guiding them. Ketamine has encouraged me to get more familiar with guiding.

Ketamine has a fascinating biological action- see a recent post for elaboration, yet it is also described as an 'abreactive drug,' that is, a drug that evokes feelings. Under the influence of the drug a patient experiences an altered state, one that can be thought of as a chemically induced hypnosis. To get the most out of Ketamine patients need a therapist in attendance to help them exploit the potential of the thoughts and feelings that are evoked by the drug.

My evolution as a Ketamine guide began with an event. I was watching a documentary on Ketamine in which the life of a young man with severe depression was being followed. There was a scene during which the patient's Ketamine infusion was filmed. As the segment ended the documentarian asked the patient's doctor whether he had ever tried the drug. The doctor answered no. I had a strong reaction to his comment. I would be nervous were I a patient about to experience a mind altering drug, and it would certainly find it reassuring if my doctor was personally familiar with the journey I was about to take. That is the essence of a guide, a guide knows the territory his client is about to traverse. Such knowledge makes the journey more predictable and safer.

So when it became clear that Ketamine was going to be available as a therapeutic option I tried it, exposing myself to a high enough dose within the current recommended dose range that I would be challenged by the experience.

I treated a number of patients with Ketamine. What follows are some of the issues that have come together as I have developed as a guide.

First, a Ketamine session is fascinating. The ground work for a session begins by getting a feel for the patient's psychology during an interview or two before exposing him to the drug. I insist that all my patients be linked in a productive relationship with a therapist, and it is helpful to talk with the therapist to see if there are some pivotal yet safe psychological issues which I, as a newcomer to the patient, can focus on in early Ketamine sessions. Orientation also involves describing to the patient some of what he might expect to experience under the influence of the drug. In particular, it's important to prepare the patient for the perceptual energy patients might experience. The latter can sometimes give patients an unnerving feeling that their ego/self is shrinking, much like the vastness of the night sky when watching fireworks can make a spectator feel relatively small.

At the outset of a first Ketamine session I am aware of a few pivotal issues in the patient's psychology and also have a sense of whether the patient is psychologically open or restricted. In either case, I'm tactfully frank with the patient about my sense of his style. If the patient is psychologically loose I'll tell him that we will focus on him having a sense of control during the Ketamine session. If they are more restricted in style, I encourage more openness. Ketamine is relatively gentle and restricted patients can rather easily ward off the effects of the drug. Obsessive patients often have good observational skills. I invite the patient to take advantage of his observational talent while being attentive to not shutting down or resisting the experience.

An actual Ketamine session lasts about an hour. Patients new to the drug are instructed to administer 40 mg- 10 mg per nasal spray alternating between nostrils. We then wait 5 minutes before dosing another 40 mg. During this initial period patients will often report a very relaxed sense of being. Once at 80 mg the patient is invited to close his eyes and self observe and try and become aware of any sensations coming from the drug- I usually allow the patient 5 minutes or so to absorb whatever experience they might have. If the patient is receptive, but not noticing much, we'll administer another 20 mg, bringing the total exposure to 100 mg. Patient and I are now 20 minutes or so into the session.

There are 3 exercises I invite patients to try in an initial session with the drug. The first, already described, is to simply develop a sensitivity to the effect of the drug, something that can potentially be resisted by more obsessive patients. The second exercise is simply to try and void the mind of directed thoughts, essentially create a blank slate, and allow a memory or situation from current life to 'pop up' into awareness. If the patient comes up with a memory that is safe to work with psychologically, I might comment on what the patient tells me if I feel I have something constructive to say. Conversely, if an emergent memory is psychologically threatening or intense, I might encourage the patient to exercise ego-strength and focus on modulating the experience. A final exercise I encourage is for the patient to take a moment to get very much 'in the moment,' that is, to allow perceptions to be experienced rather than processed: to listen to the music of a clock's tic-toc, or the flow of air in an hvac system, or the honk of a distant horn, in short, to be aware of the symphony of perceptions without trying to make meaning out of them. This latter exercise may relate to modulating the strength of the default mode network, a topic dealt with in another post.

Being a guide can be demanding while at the same time intensely rewarding. During a session the experience of time can be a challenge for a guide. Our patients are meditating we are not. I have had plenty of patients show amusement when I comment on the passage of time. I tell them, for example, we are 40 minutes into a session and they look at their watches, astounded how quickly time has passed. There is no distortion of time for the guide so sitting with a patient in silence for extended periods can be difficult. I find it helpful to quietly, and usually privately, join my patients in their meditative exercises. While my patients eyes are closed, so sometimes are mine. I do this inconspicuously because I am dedicated to the patient during our session and my meditation should not be at the expense of being attentive to my patient. I teach my patients that the states they reach with Ketamine are states that can be experienced drug free. In essence, my meditation in the room with a Ketamine patient is an affirmation of this.

If all goes well, a doctor can determine in a session or two if the patient can responsibly and safely use Ketamine on his own. Generic Ketamine is very inexpensive, amounting to around 10 dollars a session. In our practice we insist that patients getting Ketamine therapy be in a productive therapeutic relationship with a counselor. Many of these patients can use the Ketamine in the context of their therapy. The pharmacology of the drug is well suited to a one hour therapy session, and the drug's role fits comfortably into a model of 'pharmacologically enhanced psychotherapy.'

It is exciting to think that emerging drugs like Ketamine will play a role in blurring the lines between biological and psychological psychiatry. In turn, treatment models will emerge that will encourage more coordination between psychiatrists and therapists. Working in concert with a therapist a psychiatrist can take a few sessions with a patient to orient the patient to Ketamine and optimize the dose. Thereafter, patients can proceed to a qualified therapist's office and optimally use the Ketamine to enhance their psychotherapy and growth.

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