Introduction
We strongly believe that virtually all mental health patients taking ketamine should simultaneously have psychotherapy. If a patient can’t afford both ketamine and psychotherapy at the same time we would advocate ketamine first. After the patient stabilizes on ketamine, then suspend ketamine and redirect resources to psychotherapy.
This author (IbizaMalta) is skeptically optimistic that psychotherapy while on ketamine (or after a successful course of ketamine therapy) is very well worth-while provided:
1. the psychotherapist is highly competent
2. the psychotherapist’s modalities are particularly appropriate to the patient’s indication(s)
3. the quantity of psychotherapy is sufficient
The history of psychotherapy has developed slowly, in fits and starts, and was not cost-/time-effective for a very long time. The earliest modalities were various forms of psycho-analysis, quickly recognized as taking countless years to have a significant effect, if any effect at all.
This situation has changed in the last few decades. Lots of new modalities have emerged, offering vastly more evidence of their potential to help patients. I don’t believe all are equally promising. Alongside the fruit, there are doubtlessly a lot of weeds. But if we just weed through the fruitless species of psychotherapy, we will find wonderful, powerful, healing fruit.
This section on Ketamine Assisted Psychotherapy is particularly difficult to compose. First, we don’t regard ourselves as experts on psychotherapy as we do on ketamine pharma-therapy. Second, the state of the “science” of psychotherapy is nowhere near as highly developed as the science of pharmacology. Third, psychotherapy is highly subjective. Thus, more-so than other sections, this KAP section will be highly subjective and opinionated. This is unavoidable.
Why Emphasize Ketamine Pharma-Therapy over Psychotherapy?
The sicker a patient is, the less amenable s/he is to psychotherapy. The sicker patient lacks the neuroplasticity and other neurological, psychological, and emotional resources to use even the best possible, most applicable psychotherapy modalities.
When IbizaMalta was profoundly depressed, he got virtually nothing out of the first few psychotherapists he saw. The first breakthrough was when the 4th psychotherapist suspected depression (MDD) and referred him to a psychiatrist who – almost immediately – accurately diagnosed MDD. He prescribed a conventional antidepressant, which worked as predicted in 6 weeks. Perfectly.
IbizaMalta was still very sick; only the symptom of MDD was resolved. Thereafter, psychotherapy was mildly successful. His first long-term psychotherapist was a very kind, empathetic, and competent man. However, after five years of his therapy, IbizaMalta gave up. There was not enough progress to justify the cost, time, and effort.
Twenty-five years later, IbizaMalta realized a major life crisis. His life wasn’t getting better. Realizing that 25 years had passed with no improvement, he resumed psychotherapy. Again, with a very competent practitioner. Some progress, but not a lot. In the final months of that therapy (which lasted for a year), IbizaMalta began ketamine therapy. Psychotherapy began to become more effective; slightly.
At that juncture, IbizaMalta changed psychotherapists and was ramping-up on the dose and duration of ketamine pharma-therapy. The new therapist was particularly effective. More-so than every previous therapist. Five months later, IbizaMalta took on a secondary psychotherapist. And a month later, a tertiary psychotherapist. Six months later, a quaternary (fourth) therapist. All simultaneously. (Whether there will be a quinary, sentry septenary, etc., remains to be seen). He is convinced that ketamine pharma-therapy catalyzed this enormous consumption of psychotherapy. Effectiveness soared.
Ketamine alone produced enormous relief. But it did not – by itself – treat his underlying disease. That is, C-PTSD. Only psychotherapy could treat the disease. However, psychotherapy could not have accomplished much with a brain lacking neuroplasticity to take in and utilize the insights of psychotherapy.
Therefore, ketamine pharma-therapy is a prerequisite to treating the underlying disease. It is psychotherapy that treats the underlying disease. Psychotherapy without ketamine was not cost-effective; not in IbizaMalta’s case.
Ideally, one should get good, applicable, and sufficient psychotherapy con-commitment with ketamine pharma-therapy. If the patient’s resources can’t fund both simultaneously, begin the ketamine first. Realize the neuroplasticity results, then suspend the investment in ketamine and substitute psychotherapy.
What is KAP – Ketamine-Assisted Psychotherapy?
This term, KAP, is a particular sub-set of PAP – Psychadelic-Assisted Psychotherapy. It is a sibling to:
– MAT – MDMA-Assisted Therapy
– PAP – Psilocybin-Assisted Psychotherapy
– etc.-Assisted Psychotherapy
At this juncture, Ketamine-Assisted Psychotherapy, MDMA-Assisted Therapy, and Psilocybin-Assisted Psychotherapy are recognized terms. LSD-Assisted Psychotherapy or Ayahuasca-Assisted Psychotherapy have not yet emerged in the literature.
The term KAP is ambiguous and includes what we will call:
– In-session KAP; and,
– Between-dosing KAP
During the initial weeks and months of ketamine pharma-therapy it is very helpful to consult a psychotherapist between dosing sessions. Your neuroplasticity will build, and that will make psychotherapy much more effective.
It may be even more effective to take ketamine just before a psychotherapy session begins, what we refer to as in-session KAP. Remember that IV and IM infusions/injections are typically too intensely dissociative to enable a patient to simultaneously engage in psychotherapy (talk-therapy). Nevertheless, very-low or low doses of sublingual lozenges or nasal sprays may acutely catalyze psychotherapy sessions without interfering with a patient’s verbal acuity.
As one example, IbizaMalta’s prescription is for 400 mg sublingual “jolting” doses. He couldn’t undergo psychotherapy on such a high dose. Not initially, before tolerance built. Nevertheless, 50 – 100 mg sublingual doses immediately before a psychotherapy session are very fruitful. Of late, higher doses, 200 – 300, have been even more effective. A patient presents a very open, plastic mind ready to reveal unconscious sentiments and open to therapeutic interventions.
YMMV. You might find that in-session, KAP doesn’t agree with you at all. And your experience might vary over time. Accordingly, you may find alternating in-session KAP with no ketamine in-session enables you to discover the benefits and limitations of in-session KAP. Repeating the experiment every 3 or 6 months in your ketamine journey may produce varying results.
We strongly recommend ketamine patients ask prescribers for supplemental sublingual ketamine for in-session KAP to catalyze their psychotherapy.
What Makes Psychotherapy Work?
This is a tough question. Perhaps this short article “¿Cómo actúa la psicoterapia en el cerebro?” (“What Makes Psychotherapy Work?”) by Guillermo Lahera, appearing in El Pais (systematically translated from Spanish) will suffice:
“Psychotherapy is an intervention recommended as a first line – alone or together with medication – in many mental disorders: depression, anxiety, obsessive-compulsive disorder, psychotic disorder, addictions, borderline personality disorder, among others. Its effectiveness in some patients is indisputable, although we know that around 30-50% of them do not respond, have a high dropout rate, and around 10% worsen (yes, psychotherapy also has adverse effects and contraindications). The question is: when it works, how does it do it? What structural or functional changes does it produce in the brain to achieve that improvement?
The fragmentation of psychotherapy schools will produce disparate answers to this question. Cognitivists, when questioned about the mechanism of action of their therapy, will answer that the Socratic dialogue between therapist and client changes the interpretation of reality, questioning and reversing certain automatic thoughts and biases that lead to discomfort and symptom (I am simplifying). This would hypothetically result in brain changes in the areas involved, especially a hypoactivation of structures such as the amygdala or cingulate cortex.
Psychodynamic therapists will emphasize the patient’s ability to identify and know during therapy their own mental mechanisms to get an insight, an awareness of the problem. This self-knowledge or self-analysis has – hypothetically – its brain translation, as shown by the incipient studies of neuropsychoanalysis (I recommend the works of Mark Solms).
Therapists who use meditation or mindfulness will indicate that the thickening of the insula—a network center that reaches a multitude of body connections located deep in Silvio’s fissure—is the product of the integration of sensory and visceral signals from the present, at the cost of reducing useless ruminations about the past and future. Other authors in the field of therapy will answer that what happens in the brain is an inconsequential fact, a mere correlation, which is not even interesting to know. We are varied and diverse, it is a fact.
But this multiplicity of voices in psychotherapy – and the frequent fratricidal struggles between them – has been contested for years by the integrative movement, which allows different perspectives and formulations to be incorporated, emphasizing the so-called common factors of therapy, that is, what the different schools have in common, not what separates them. In a meta-analysis that will go down in history, Bruce Wampold dissected the role of common and specific factors of therapy, concluding that the first ones are much more relevant: the empathy shown from the beginning by the psychologist or psychiatrist, the genuine agreement between therapist and patient about the goals to be achieved, the working alliance, the validation of the client’s experience, the ability to generate expectations of change and the personal characteristics of the therapist beyond the theoretical model used (the human factor, as Graham Green would say).
Assuming this new paradigm, the study of the mechanisms of action of psychotherapy then focuses on knowing how this therapeutic relationship generates changes in the brain to move from intolerance to stress, emotional dysregulation, dissociation, or maladaptive behavior to a state closer to mental health.
One clue is that most of our cortex develops in an experience-dependent manner through attachment, i.e., interpersonal experience triggers gene transcription. Thus, the child’s neuroplastic brain develops to the extent that it dynamically interacts with its attachment figures. There are factors that favor this development: a secure relationship based on trust, certain stress (trauma slows down child development, but hyperprotection and the absence of stress, too), some emotional and cognitive activation, and – most importantly – the co-construction of a new personal narrative (which in the child is the creation of his own identity).
These same factors that promote neuroplasticity in child development are those that could act in therapy. The therapist-patient relationship (with its framing, its limits, transference, and counter-transference) acts as an emotionally corrective experience in which the patient feels heard, validated, questioned, and supported to produce change. After therapy, at the brain level, we see a top-down integration.
Through the dialogue that re-evaluates, analyzes, and considers long-term goals, the emotional reactivity of the amygdala is reduced, activating, to a greater extent, that of the prefrontal cortex. Two prefrontal areas with different functions are also integrated: the dorso-lateral, responsible for the evaluation of the context and the prediction of reality, with the orbito-frontal, related to emotions, motivations, and impulses.
We would say that the perspective is integrated in the first and third person (it is logical, the patient tells himself his life story). In therapy—especially of patients with adverse experiences in the past—high-stress memories (of the amygdala) are integrated with normal, episodic (hippocampus) memories.
And how does this integration occur? Through the irresistible power of narrative. Just as a child understands many abstract concepts when listening to a story from his father at night, the patient fits, dampens, regulates, and integrates many psychic functions to the extent that he co-constructs with the therapist a new story of his life. The patient comes to the consultation with a saturated, exhausted narrative (“I want to die,” “I can’t take it anymore,” etc.), and the safe dialogue that it generates with the therapist favors such that it transforms and expands toward a more useful account of the facts, which involves more adaptation.
The last, almost, is the myth in which this new construction rests, be it the Oedipus complex or the systemic analysis of the dysfunctional family; the important thing is that it is a new story that resignifies what has been lived. As Will Storr recalls in his recent book The Science of Storytelling, humans are robbed of a story that orders our experience, that makes us both protagonists and spectators, in which we come out well (that without a doubt), that recalls foundational myths of our biography, milestones, and difficulties that we managed to save, that gives us a sense of coherence to the chaotic, indecipherable, random life experience.
Nations need these stories (some based on remote historical facts, others on mythology) to generate national identity. Families have stories – sometimes terrible – that come from the past and that produce in the nephew, in the great-grandson, a strange sense of belonging. Tormented subjects, drowning in pain, need to discover, together with a reliable person, a new story of themselves. Sometimes, it is not necessarily truer, but more useful. That’s why, perhaps, psychotherapy works.”
Did psychotherapy fail to deliver results to you (without ketamine)? IbizaMalta is not surprised. Will ketamine make psychotherapy fruitful for you? That is our prediction.
Face-to-Face or Tele-Therapy?
Each patient will have access to 0 / 1 / few / many psychotherapists within ready driving distance from home.
If you have many candidate psychotherapists to choose from, you can consider the luxury of the human interaction of face-to-face therapy. I think that’s really a significant advantage for most people. Conversely, for some especially timid patients, face-to-face therapy can be intimidating.
We suspect that, for better or worse, tele-therapy will be the wave of the future. There are too many advantages to tele-therapy that offset the disadvantage that it is probably less effective.
Tele-therapy lowers the therapist’s cost of delivery. S/he can work from home via tele-therapy and avoid the overhead of maintaining a separate office space. And, s/he eliminates the cost and inconvenience of commuting to the office. That cost savings can inure to the benefit of the patient.
Tele-therapy opens the world of therapists available to each patient beyond the limitations of a reasonable driving distance. Each patient can consider thousands of candidate therapists.
Tele-therapy enables patients to seek out the lowest-priced source of psychotherapy. Psychotherapists in the US charge in the vicinity of $150/50-minute “hour.” Their competitors in low cost-of-living countries charge in the vicinity of $50/60-minute hour.
Finally, the patient can video-record the session and play it back several times before the next season to pick-up on points that may have been missed in the live session or to reinforce the interventions of the live session.
Licensing of Psychotherapy
Psychotherapy is a state-regulated profession. So far as we know, this is the case throughout the United States. Therefore, the therapists you consider must be licensed in the state where you are located when you are in-session. Some states have reciprocity agreements such that a licensee in any such state can see a patient located in any other state participating in that reciprocity agreement. If the state of your home address participates in no such agreement, then your choices of therapists are relatively limited. Conversely, if your state participates in such an agreement, you can see – via tele-therapy – practitioners in any state participating in that agreement.
Occasionally, you will find a therapist licensed in multiple states. There is no need for a reciprocity agreement when such is the case. When you see a posting for a psychotherapist, it should mention: “Licensed in: AL, AK, and WY” for example, a listing of three states.
To some extent, practitioners can try to skirt this licensing limitation by characterizing their services as “counseling,” “coaching,” or the new term “integration.” If challenged, they will insist that they never advertised or characterized their services as falling within the scope of the term used to designate the licensed profession, e.g., such as “psychotherapy.” This work-around has made possible several on-line tele-services typically characterized as “psychedelic integration.”
Another work-around is to find psychotherapists who work from foreign countries where their licensing regimes are non-existent, or light. Your home state’s licensing agency simply can’t, or won’t, attempt to expend its resources trying to assert jurisdiction over a practitioner who is located outside its jurisdiction. You are not within their jurisdiction because you are the patient, not the practitioner. IbizaMalta gets most of his psychotherapy from three therapists in Mexico, only a little from an American psychotherapist.
The Personal Qualities of the Psychotherapist
Suppose the thesis is true as described in the short article quoted under “What Makes Psychotherapy Work?” above. I.e.,
. . . the empathy shown from the beginning by the psychologist . . . , the genuine agreement between therapist and patient about the goals to be achieved, the working alliance, the validation of the client’s experience, the ability to generate expectations of change and the personal characteristics of the therapist beyond the theoretical model used . . .
If so (and we agree), then it is indisputable that the personal qualities of the psychotherapist are paramount. Probably more important than the goodness-of-fit of the therapist’s modality(ies) to the patient’s indication.
And here, we confront the most difficult problem in writing this section. Could you imagine the proposition?:
‘All psychotherapists’ personal qualities are adequate to the needs of all patients.’
This proposition is absurd on its face. Psychotherapists are human beings, just as are their patients. I’ll hazard the guess that they have been as mentally ill as most of their patients. The unknown question is whether they have healed before practicing psychotherapy.
The Hippocratic Oath admonishes:
Physician, first heal thyself!
We hasten to paraphrase:
Psychotherapist, first heal thyself!
Tragically, the diploma and license on the therapist’s wall do nothing to assure the patient that the practitioner has sufficiently healed him/herself to do any good for the patient.
The best advice we can offer is: caveat emptor! Buyer beware! Or, in this case, patient beware! If, early on, you get the sense that your therapist:
– isn’t successful in cultivating a therapeutic alliance with you;
– isn’t sufficiently free of the grip of his/her own ego;
– isn’t genuinely invested in your personal objective of healing;
– is more interested in achieving and maintaining a monopoly on your resources for healing;
– isn’t empathetic and validating; . . .
then these are signs that this therapist isn’t likely to be effective or cost-effective enough to help you heal. It is better to cut your losses and resume your search for a better therapist.
IbizaMalta has used a dozen psychotherapists over a 35-year span of time, most of them recently. He considers himself lucky that half of these seemed competent and useful. As to the other half, “The fault, dear Brutes, lies not in our stars [nor in our therapists], but in ourselves!” Perhaps some of the others were competent, but the patient wasn’t fit to profit from their services.
I strongly recommend the book: “The Audacity to be You: Learning to Love Your Horrible, Rotten Self” by Brad Reedy. It’s by far the best book on psychotherapy and boundaries I’ve read. If you read and digest it, you will understand how to select your best candidate psychotherapist and reject those who can’t possibly help you.
Another selection criterion is: ‘unconditional positive regard.’ (https://www.amazon.com/Unconditional-Positive-Therapeutic-Conditions-Evolution/dp/1898059314/ref=sr_1_1?crid=2BVBS4B0R10NB&dib=eyJ2IjoiMSJ9.CyftherB20pUNYIUkaOf50GaENJjp7-fE1g3Xbj0Fn1TG-eAqWvZJABWqig6LvwGlKuhvVpz_xT1-A8Klj8qQFC6OZe6D7Sr1D7AhY8HrQkCXQOewYnGVdZ_uvHcqi63xzuCugp3tMM4cqHpUBEAlKzdrmdWeljzxQT8ce9RxAh1eyNKiLddOeqCFOuzXEwH25-5w1O77LPS6SIa96yqBUqPywjLtFIiS72yuE9–Qg.kssk6GD9F3UrpJQqmfganE3mC5nPyflSORtYST6p3c8&dib_tag=se&keywords=rogers+therapeutic+conditions&qid=1705586893&s=books&sprefix=rogers+theraputic+conditions+%2Cstripbooks%2C106&sr=1-1). In other words: How do you feel your psychotherapist regards you? Is it your sense that s/he regards you in any way negatively? Or, that s/he regards you in every respect positively? And is this poisitive regard unconditional? Do you sense that s/he will continue to regard you poisitvely notwithstanding that you do not embrace her/his worldview or opinions wholeheartedly? If so, s/he conforms to this critieria of unconditional positive reguard. If you do not sense that s/he so holds you in this reguard, then she is unlikely to be able to help you at all. You will never trust her/him.
The Psychotherapist’s “Modality(ies)”
In psychotherapy-speak, the school-of-thought, philosophy, and kit of techniques is called a “modality”. Typically, a given therapist is apt to specialize in one modality and be trained, or at least self-studied, in a few others. It’s a relatively good sign if a candidate therapist tells you that s/he has been trained (or at least self-studied in) and regularly utilizes multiple modalities.
Not all modalities are equally effective across diverse mental health indications. And, certainly, some modalities are well-suited / ill-suited to particular mental health indications. Depending on your personal diagnosis, you should research which modalities are considered especially well-suited to your diagnosis/diagnoses.
We wish we knew enough about which modalities apply to which indications (diagnoses) to provide some recommendations. Unfortunately, at this point, we don’t know enough to attempt such a recommendation. Perhaps someday we will say more about this.
Nevertheless, it seems prudent to point out that if you throw a dart at the Yellow Pages, you are apt to hit a candidate therapist whose modality(ies) aren’t necessarily particularly well adapted to your diagnosis or your taste in modalities. Accordingly, we recommend you do some of your own research along two lines:
1. – first, get a diagnosis of your particular mental health indication(s). This will be your starting point.
2. – next, research which modalities are deemed particularly applicable to your indication(s).
3. – finally, narrow your search criteria to therapists who advertise that they use one of the modalities applicable to your indication(s).
If your condition is serious enough that you are considering ketamine pharma-therapy, then we believe it’s likely that it’s serious enough that a modality deemed a “brief” therapy is less likely to be useful in the long run. Brief therapy may provide more immediate relief in terms of improving your coping skills. However, it’s less likely to help you resolve the fundamental issues at the root of your symptoms.
To try to give you a feel for your choices among modalities, I’ll use a crude analogy. Suppose you have an old car. It needs some work. You need to find an auto mechanic to do the work it needs. What are the possibilities? What’s wrong with the car? You may have only a vague idea. Your range of possibilities includes:
– a restorer who will disassemble every component and refurbish everything, including the fine-grained woodwork on the dashboard.
– an overhauler who will build the engine, drive-train, breaks, and anything else subject to wear and tear.
– a tune-up guy who will replace the fuel injectors, spark plugs, and wires;
– a guy who will replace some moving parts, such as the timing chain or alternator
– a break-job guy.
The typical mental-health patient is in much the same situation as the less-than-well-informed automobile owner. S/he can figure out that s/he doesn’t want a restorer and can probably figure out that it’s not just a break-job that’s required. But whether the engine and drive-train need to be rebuilt, just a tune-up, or some moving parts replaced is hard to tell.
IbizaMalta’s four psychotherapists specialize in: gestalt, coherence, EFT-Tapping therapy, and art therapy modalities. Gestalt is analogous to an overhaul of the psyche. It’s not brief, but it’s thorough. It provides slow but hopefully sure repair of most – if not quite all – of the aspects of a patient’s maladaptive psyche. While that extended process is underway, other things need to be fixed. Undoubtedly, the patient has particular blockages that stand in the way of daily living and also in the progress of the overhaul of the psyche. Coherence therapy seems to be very effective in fixing these blockages. And it can do so in an hour or two when the circumstances are just right.
When the patient is typically triggered, s/he doesn’t fare well because the parasympathetic nervous system isn’t intervening to prevent the sympathetic nervous system from running away with a Fight / Flight / Freeze / Fawn response. This situation is analogous to a worn-out, maladjusted timing chain. EFT-Tapping seems very effective in addressing this problem.
Using all three of these modalities simultaneously delivers considerable prompt relief by Coherence and EFT-Tapping therapies. This aids considerably in facilitating long-term progress on the gestalt “overhaul” of the psyche.
IbizaMalta recommends Coherence and EFT-Tapping as fast-acting – albeit only narrowly focused partial remediation of his problems. He recommends gestalt therapy as a long-term solution. Nevertheless, these are just three out of 60 – 100 modalities. No doubt there are other modalities competitive with these three, and IbizaMalta has no wish to emphasize these three modalities over all the others with which he has had little or no exposure.
Attunement, Empathy
As important as modalities might be, the therapist’s ability to attune to your mental state and empathize with your experience is still more important. Plenty of lip-service will be given to these personality qualities of the therapist, but it’s these qualities that are at the core of what will make for a successful therapeutic alliance. See “The Audacity to be You; Learning to Love Your Horrible, Rotten Self” by Brad M. Reedy, PhD:
“. . . [M]y friend had a fundamental misunderstanding of the healing mechanisms of therapy. He thought of it as a place where you gather information, tools, skills, insights and ideas. While these things happen in therapy, that is not what makes therapy unique from reading a good self-help book or listening to a great lecture on relationships or psychology. Skills, tools, ideas, and solutions can be discussed in therapy, but that is not the same experience of being in therapy. We can be told we are okay, but we must experience actually being okay by having someone reflect that back to us again and again. The experience of therapy is sitting with another and risking the reinjury that our earliest context inflicted on us — the response that suggested that something with us was not right. The thing that differentiates therapy from those other experiences is the experience of sitting on the couch and telling your truth at the risk that the therapist will respond in a way similar to those in your past and recreate the feeling something is wrong with you, thus causing you to feel shame. . . . Therapists who respond to clients with an eagerness to fix or to change the client, hide behind a professional guise but provoke the same feeling of shame. This response is more insidious because it is hidden behind psychologically complex language and delivered from the throne of the therapist expert. The therapist’s eagerness to help may be internalized by the client the same way the mother’s fear or frustration was by the young child: something is wrong with me. . . . . Graduate schools and professors arm their students with the latest theories and research in the field of mental health. This can lead to a misunderstanding for young therapists that the key ingredient in therapy are these concepts and tools. . . . Adequate therapy (that is the highest praise I can attribute to a therapist) is not about the theory or the techniques. . . . Phrases like ‘evidence-based’ and ‘the research suggests’ are their deities and they take pride in citing experts and studies. They have a list of skills at the ready and refer to the manual.”
Thirty years ago I was seeing such an empathetic therapist. At the same time, I took gestalt therapy training from his wife and took therapy from her on several occasions. I never established a therapeutic alliance with her. The two therapists so closely juxtaposed in time exemplified the difference between an empathetic “other” vs. a “Therapist[ ] who respond[s] to clients with an eagerness to fix or to change the client, [who] hide behind a professional guise but provoke the same feeling of shame.” I sensed something was wrong with my gestalt therapy teacher, but was too ill-informed to recognize what it was. I just knew it wasn’t working with her.
Cognitively, I recognized the importance of the felt relationships with my therapist(s) for as much as a year during my current round of therapy (2022-2024). Yet, emotionally, it had yet to really sink in. Until one day, I was in session with Paula, my quaternary therapist. We were hardly speaking at all. Our time was 90% silent on both our parts. Where was the “talk- ” in the talk-therapy? Nevertheless, I had slid gently into a profound state of bliss. This experience was repeated in subsequent sessions. I am not saying that, with this therapist, we don’t talk or rarely talk. We do sometimes. But much less than with my other therapists. After repeating this sliding-into-a-blissful state without talking with Paula, I began to notice the same experience occasionally with Sofia, my primary therapist.
What’s going on here? Initially, I thought Paula had some magic touch; the ability to cast a mysterious spell over me. But if that were so, it should happen with her other patients. Not so. Paula tells me that no other patient has ever told her this. I’ve quizzed a couple of my friends who also see Paula. Nope, they think she is great, but they don’t experience this blissful state. Somehow, Paula’s mysteriously shaped therapeutic-personality “peg” seems to fit into my emotional “hole” uniquely. This experience only manifested with Sofia after 200 hours of therapy; after it first appeared with Paula. It hasn’t manifested with either of my other two therapists.
Where is the magic? I have yet to figure this out. It’s not purely in Paola because it began to manifest with Sofia, too. But only recently. The constant here is in the patient. Somehow, the magic is partly in the patient’s developing sense of trust and attunement in these two therapists. But the same sliding-into-a-blissful state doesn’t manifest in therapy with the other two therapists. So, some of the magic is in Paola’s and Sofia’s rare ability to attune with IbizaMalta’s inner state.
My experience with Hannah, my secondary therapist, is very different. She is very personable and very empathetic. But it’s not much talk-therapy. It’s more like she interviews me about the issue I’m pursuing with her. She does a very experiential intervention. And these interventions can be remarkably emotional. I sometimes feel my emotions are in the agitation cycle of a clothswasher.
My experience with Amar, my tertiary therapist, differs greatly from the others. It’s about 1/3 talk-therapy, 1/3 interview to understand the issue I want to pursue with him, and 1/3 the EFT Tapping technique.
Your mileage will vary. I encourage you to look first for early signs of the therapist building an empathetic bond with you. If you don’t see that emerge, it’s time to consider whether this therapist is right for you.
Bear in mind that you are the patient. You are in therapy because you are psychologically wounded. Your resistance to developing a therapeutic alliance with anyone is high. Whoever is your therapist, she will have her work cut-out for her. She will find a way to make that therapeutic alliance sprout and budd if she is talented enough. She may be talented but still fail to achieve that goal with you. And, if it’s not happening in 6 or 9 sessions, it’s time to reevaluate her suitability. You might do better with someone else.
Be prepared. You might be a particularly tough nut to crack. Your attachment style may be so profoundly wounded that you can find attunement in nearly no one. But you must persevere. Continue the search until you find a therapist who has enough of the “magic” to pierce your resistance to recognize her attunement, her empathy. It’s a waste of your time and money to continue with any therapist who isn’t making progress in this awesome task: transcending your understandable resistance to attunement and empathy. It’s not your fault; it remains your responsibility to find the therapist who can help you.
How Much Psychotherapy is Enough?
Answering this question is really tough. How many months or years of psychotherapy will it take to resolve your issues? That will depend on a myriad of conditions too complex for us to contemplate. If your disease is serious enough to call for ketamine pharma-therapy, you should not expect to spend months in psychotherapy. Instead, it will probably be years.
In the first 16 months of my current campaign of intensive psychotherapy, I’ve had 500 hours of sessions. At the rate of 50 sessions per year of 50-minutes duration, that’s the equivalent of 12 years of psychotherapy at the customary rate of one 50-minute session for 50 weeks per year. I’ve made a lot of progress but I’m still not “cured”. I’m a particularly difficult patient to treat; hopefully, you are easier to treat. But do not imagine that psychotherapy will be a quick cure.
Nevertheless, psychotherapy concurrent with ketamine pharma-therapy will be invaluable to cope with whatever comes up during and after dosing. Expect to need at least a few months of psychotherapy to help you cope with your initial ketamine therapy.
The convention in America is that psychotherapy patients take a single session per week lasting 50 minutes. The so-called “50-minute hour”. There are exceptions, but this is the norm. This conventional “budget” of a single 50-minute session per week hardly seems justified in light of the diversity of indications, their severity, and the varying capacities of patients to benefit from psychotherapy. So why is a single 50-minute session per week conventional?
The justification seems three-fold:
1. – insurance companies will generally only pay for a single 50-minute session per week;
2. – psychotherapists must fit patients’ appointments into a well-ordered schedule of hourly sessions; and,
3. – fully-booked psychotherapists have either zero, 1, or 2 open hours in their calendars. It would be hard for them to juggle their existing caseload to give a patient two consecutive hours or two single hours widely spaced in the week’s days, e.g., Tuesdays and Fridays.
And so, institutional rigidities and customs have operated to make a single 50-minute session per week the convention. Does this little amount of therapy make sense for the patient?
No doubt, in some cases, it does. If a patient’s suffering isn’t too severe, then one session a week is enough. If the patient can’t take in more therapy than an (available) therapist could deliver, then that’s that patient’s capacity. Patients often need seven days between sessions to absorb what they have learned in the previous session.
Nevertheless, if your condition is serious enough that you are considering ketamine pharma-therapy, then we believe it’s likely that you would benefit from more than a single 50-minute session per week.
IbizaMalta gluttonously consumes 8.5 hours of psychotherapy per week. He will acknowledge that he probably isn’t able to digest as much therapy as he takes. Nevertheless, he gets most of it so cheaply that he can afford to over-buy psychotherapy.
Most patients can only afford a single 50-minute session per week. Either because:
1. – they have insurance that will pay for only a single session per week, and the patient cannot afford to pay the full cost (without additional insurance reimbursement) of an additional session or an additional hour.
2. – they have no insurance and can barely pay for a single 50-minute session in their weekly budgets.
You’ve undoubtedly heard the expression: ’Sipping from a fire hose.’ That’s what IbizaMalta is doing with the quantity of psychotherapy he buys, yet he can’t possibly consume. But is this true? Is it really true that he isn’t fully consuming all this therapy?
The conscious mind can take-in only so much information at a time. When reading a difficult passage in a book, the mind concentrates carefully on each sentence and each word. It works very slowly. Yet, the unconscious mind does not necessarily work in the same way. Imagine standing at the edge of the Grand Canyon or at the foot of a mountain range or a forest. The body/mind seems as if it can soak up the entire scene’s grandeur.
It is, at least, conceivable that the human organism can immerse itself in an experience and absorb unconsciously vastly more than meets the eye, ear, and conscious mind alone. And that the resulting healing takes place and manifests slowly over time. Not with the conspicuous efficiency of the production line. Rather, it is more like the process of fermenting or aging wine.
What are the comparative experiences of immersing one’s body in:
– a bathtub
– a swimming pool
– a lake
– a sea
They are each one and the same. The body has a finite surface area to expose to contact with the water. Each is a cleansing, healing experience. Yet, to the psychological organism, they are incomparable. Immersion in the tub / pool / lake / sea are simply dramatically different experiences. The “law of diminishing returns” seems not to apply at all.
And this is particularly so if – as described above – the magic is in the experience of an empathetic, attuned, therapeutic alliance. How many hours per week of the attunement and empathy of an “other” can you effectively absorb? Is it really limited to 50 minutes?
Multiple Psychotherapists – Poly-Therapists
This section will doubtlessly be the most controversial of all in this article. If I have insufficiently outraged the psychotherapy community to this point, here I will turn them into a raging mob.
IbizaMalta simultaneously sees four different, unrelated psychotherapists. His primary gets 4 hours weekly (reduced from 6/week during the first 10 months). Secondary gets 1 hour a week. Tertiary gets 1.5 hours a week. The quaternary gets 2 hours a week. I call this poly-therapist. (One who maintains multiple sexual partners is said to be poly-amorous. One who worships many gods is a poly-theist. I maintain multiple psychotherapists – a poly-therapist.)
Problem statement: Each therapist you try has a high probability of being a dud. If you try one therapist, he is probably going to be a dud. If you try two therapists, both are probably going to be duds. If you try three therapists you have a sporting chance that one of then will be a keeper. How do you solve this problem?
If you can (somehow) afford to do two sessions per week, consider engaging two different therapists using two different modalities. If both therapists practice multiple modalities, ensure their primary modalities differ. E.g., if the first therapist uses as his primary, secondary, and tertiary modalities: A, B, and C, ensure that the secondary therapist’s primary modality is not A. And, preferably, that the secondary’s primary modality is not B either. To reap the most benefit from multiple psychotherapists, it is best that they use complementary modalities to pursue your issues on multiple fronts.
Assuming, in most cases, that a patient can’t afford two sessions per week, consider seeing each therapist on alternate weeks. This approach won’t strain the budget (or insurance benefit limitations) while at the same time allowing the patient to experience multiple therapists’ personalities and their respective primary modalities.
Suppose you meet just one person who models benevolence and empathy toward you. Since your schema is rigidly fixated on “I’m unloveable,” it’s easy to dismiss that one person as an outlier. That s/he’s highly talented in exhibiting this countenance. ‘It’s because s/he’s my T. That’s her/his job to be that way with me.’ You will dismiss this evidence as an outlier, a fluke.
Nevertheless, the more such people you encounter and experience intimately, the harder it will be for your schema to continue to dismiss all of them collectively as outliers, flukes. Subconsciously, you will begin to absorb the recognition that there really are many people who empathize with you. It’s harder to sustain the conviction that “I’m unloveable” when many people find you lovable.
You will begin your psychotherapy experience shopping for your first therapist. Before making a selection, we urge you to interview several candidates, at least three, and preferably more.
Seeing two different therapists (specializing in different modalities) on alternate weeks (assuming you can’t afford two sessions a week). You will, at least, be able to compare your experience with these two.
Expect to like one more than the other. Expect to sense that one is more useful than the other. If the differential is significant, drop one and find a replacement for the one you dropped. If that replacement stands head-and-sholders above the other therapist you continue to see, consider searching for a fourth therapist to replace the one you judge inferior. If that fourth therapist seems much better than the inferior therapist, then drop the inferior therapist. This strategy will likely prevent you from getting stuck with a single therapist who just isn’t getting you anywhere.
Once we start with a single therapist, we are apt to get “invested” in the idea that we have already spent 50 – 100 – 150 hours with this single therapist and are reluctant to start from scratch with a replacement. Reluctant, notwithstanding that we are dissatisfied with our progress with this single therapist. Those hours represent a financial expense of $5,000 – $10,000 or $15,000 – without insurance coverage. Or co-pays of $1,500 – $3,000 or $4,500 if one has insurance. We can’t tolerate writing off such considerable sums of money.
The suggested strategy will likely enable you to write off your investment of 5, 10, or 15 sessions when you sense that one or another therapist isn’t right for you.
I began this section by pointing out that it would be controversial. My primary psychotherapist takes the lead in criticizing my advocacy for poly-therapist. I have great respect for her opinion. Nevertheless, it was she who initiated my practice.
When I wanted her to incorporate more Coherence Therapy in her treatment of me, she told me in no uncertain terms that if I wanted more of this C-T modality I would have to find a practitioner trained and experienced in it. I.e., she told me to step out on her. When I discovered EFT-Tapping she referred me to her own EFT-Tapping practitioner. (I kept the one I found.) It’s not that she couldn’t do these two modalities. She could. She did. She is excelent at them. But she would not do as much of these modalities as I wanted. So she told me to shop elsewhere. She does not object to poly-therapist in my case. Only that she thinks it appropriate for only rare patients.
My other three psychotherapists don’t articulate objections to poly-therapists. If my team is 3:1 in favor of poly-therapist I hold my practice and advocacy as reasonable notwithstanding my critics’ opinions.
In discussing my practice with my tertiary T, he recalled his brother’s auto accident. He was badly injured in his face and brain. The hospital took a team approach to his treatment. Many specialists were called in to attend to diverse aspects of his treatment. Even a nutritionist was called upon to help him for weeks when he couldn’t eat. If such a team approach – multifaceted concerning modes of therapy and viewpoints – applies to physical illnesses, it should be ever more applicable to mental illness.
If all doctors were gods, we would not hear the adage to “get a second opinion.” Doctors are not gods; they are fallible and limited in their focus. So too, psychotherapists are not goddesses; they too will overlook some aspects of your mental illness.
I have a roster of over a dozen physicians. A: cardiologist; endochronologist; family doc; hemotologist; internist; neurologist; ophtomologist; psychiatrist; pulmonologist; sleep doc; general surgeon; and, urologist. And my son is an ob/gyn. I practice poly-physician and see poly-therapist as equally reasonable.
Several of my Redditor fellow journeyers have adopted poly-therapists and are delighted with the results. It’s not just IbizaMalta who has found this way of psychotherapy useful.
My advocacy of poly-therapist notwithstanding, there are pitfals and limitations to this practice. For one, a therapist is apt to disapprove of any client seeing multiple therapists. What’s going on in such a case? Is it the therapist’s ridged thinking on the subject of poly-therapist? This isn’t done; so, it must not be a good idea. So what if it isn’t done, to the best of that therapist’s knowledge? It still might be a good idea; or a bad one. It might be a good/bad idea for some clients, but certainly not all.
Therapists are apt to be reluctant to schedule a client for alternate week sessions (allowing the client to see another therapist on alternate weeks.) Therapists will prefer to fill their calendars with patients who come every week at a given day+time. They might find it hard to find a client willing to take the appointment day+time on the alternate weeks left open to accommodate a client who wants only an alternate week schedule.
Beware of the temptation to “opinion shop” with multiple therapists. If you don’t like the analysis offered by one therapist, you might ask for a different analysis from the other therapist. What’s going on here? Are you going to struggle to integrate the two opinions? Are you going to accept the opinion that better accommodates your ego and dismiss the other opinion that might be challenging to your worldview? Is one therapist on-target and the other missing the mark?
Whether you see just a single therapist or two or three, you must take responsibility for your own presence in each session and with each therapist. Poly-therapist works very well for IbizaMalta, but it might fail miserably for you.
You might not think of this, but psychotherapists have their own lives to pursue. Sometimes they move to a different city; or take a job with a different practice. They go on vacation or take a break for holidays. They die, or pursue a different career. Go on maternity leave. Most of these contingencies have occurred with one or another of my mental health practitioners over the years.
I’m insulated from such contingencies by using poly-therapists. When one of my therapists isn’t available I can call for support from the other three. Generally, I can get an impromptu session from one of them within a few hours or a few days at most.
If you have only a single psychotherapist then you are vulnerable to having no one available to you when a crisis occurs in your life. Or, you are vulnerable to finding a new therapist when some contingency arises in the life of that one therapist.
Cost
American psychotherapists’ rates typically range between $100 – $180 per 50-minute session. A few are less expensive. Some are more expensive. Insurance reimbursements and co-pay requirements vary by the therapist’s policy and in-network/out-of-network status.
If you have 45 seasons a year for $100 each, that’s $4,500 per year. Even a $30 co-pay amounts to $1,350/year. That will cost you more than your ketamine pharma-therapy if you pay out-of-pocket or almost as much as Joyous’ pharma-therapy if you only paid a co-pay.
Such are the circumstances we face in buying psychotherapy in America. It works well enough if:
– you have medical insurance, including psychotherapy
– the number of sessions insurance will pay for is open-ended or at least extensive
– the co-pay is modest
– you suffice with a single 50-minute session per week
When one or more of the foregoing doesn’t apply, the patient has an economics problem.
I found the solution. Find a psychotherapist in a low cost-of-living country and pay the comparatively low rates that therapist charges in her market. Of my four psychotherapists, three are in Mexico; only one is in the US. The US therapist is partially covered by insurance. My primary charges me $35/hr for 4 hours a week. My tertiary charges $67/hr for 1.5 hours a week. My fourth therapist charges $35/hr for 2 hours. My secondary charges $120 less $90 in insurance for 1 hour a week. It’s realistic to find tele-therapy in low cost-of-living countries at rates between $40 – $60/hour.
Finding psychotherapists is hard enough in one’s own city or state. The internet has made the process easier. That same internet is your tool for finding psychotherapists in low cost-of-living countries. Target a country, let’s say Mexico, and search for psychotherapists using the search term in that target country’s language, e.g., “Psicoterapeutas en Mexico.”
You need only a modicum of capacity in Spanish to browse the returns looking for promising candidates to build a long-list. If you are fluent in Spanish, you are home-free. You will have no difficulty finding Spanish-speaking therapists in Mexico. Conversely, if you are not fluent, you need to find candidates who can and are willing to give therapy in your language. In Mexico, plenty of therapists are able, but fewer are willing to give therapy in English. Your search will be longer.
Bear in mind time-zone differences. Searching Latin American countries works well for Americans because we have the same time-zones. Searching in India works well for English-speaking therapists, but the time-zone difference is 6 – 8 hours. Indians are accustomed to working across this time-zone differential. Still, it’s a stretch; you need to have enough flexibility in your time-availability to find a time slot your foreign therapist will accommodate.
We will, eventually, strive to list foreign psychotherapists in our Provider Directory along with Americans.
Selection Criteria to Consider for a Psychotherapist
Before you start your search, it’s worthwhile to think about your wants, needs, and desires, about the characteristics of an ideal/acceptable psychotherapist. Characteristics to consider might include:
– Male/Female
– Straight/G/L/B/T/Q
– Personality
– Language
– Licensing/Reciprocity
– Face-to-Face / Tele-therapy / Phone-therapy
– Venue: Therapist’s salon/home/third-location
– Modalities
– – list by classification of modality
– – list by your indication/diagnosis/complaint
– – matrix of a key classification and indication
– Insurance, in-network/out-of-network/not-reimbursed
– Affordability
– Time-slot Availability: T’s vs. Your’s
– Availability outside a session (text, email, phone)
– Talent of T
– Has the T endured your indication? Has she healed herself?
– Personality/warmth/transparency/opaqueness
– Culture of society and school of therapy
– Single/multiple Ts; tolerance for you having multiple therapists
– Quantity
– – Hours-per-week
– – Hours-per-session
– – Sessions per week
– Training/experience of T
– Is the T familiar with your indication? Trauma-informed? Borderline-informed? Bipolar-informed? etc.?
– Medicated while in-session? Does the T support PAP/KAP?
– Is the T trained-in/experienced-with PAP? Is she supportive of PAP?
– Is it important that your T be trained/certified in KAP specifically? Or MAT or xAP? Or is any awareness of PAP sufficient?
– Timing of psychotherapy relative to the time of coming up on ketamine or any other drug
– When to bail-out of a reasonable attempt with a particular T?
– When it is the T’s problem rather than your problem?
The foregoing are merely points to consider. Some will be controlling, such as time-availability in your respective schedules. Some will be important to one patient and unimportant to others. How you feel about having a male therapist depends on whether you have issues with males vs. females. And so forth.
Conclusion
There is no logical conclusion to this topic: Ketamine-Assisted Psychotherapy. We could devote a whole separate website to the topic. And it’s difficult to cover. Hopefully, we’ve given you much food for thought to empower your search for your initial therapist(s). We will have more to add in the months to come.
As you begin psychotherapy, return to this section to read it repeatedly. Something that didn’t quite make sense in your initial read might be better understood as you begin your journey through psychotherapy.