Here are the basics of psycholytic and psychedelic ketamine-assisted psychotherapy.
Psycholytic Therapy
Psycholytic approaches to medicine-assisted therapy use low doses with greater frequency. Doses are typically administered orally through lozenges, though intranasal administration is practiced as well. The goal of a psycholytic session is not ego dissolution or self-transcendence; rather, it is for a client to experience a non-ordinary state of consciousness while remaining in touch with the present moment, and by extension the therapist.
Jason Sienknecht, LPC, is a core trainer for PRATI’s ketamine-assisted psychotherapy training program. In his practice, Sienknecht utilizes both psychedelic and psycholytic approaches, depending on the client’s unique needs. He explains that psycholytic therapy induces a “trance state” that allows the client to “remain in the room.”
This approach allows for clients to work directly with material at a conscious level. Low doses of ketamine can facilitate a slight removal from sticky content and patterns, and this opens the potential for the client and therapist to work with that content from a different vantage point. For instance, someone struggling with addiction to a substance or behavior may gain new insight into what unmet needs underlie that addiction. A skilled therapist can then offer prompts and questions to deepen the client’s process without taking agency away.
(ADD: Low level dissociation occurs, but clients maintain their capacity for dialogue and awareness of the physical space.)
Psychedelic Therapy
Psychedelic therapy, in contrast, aims for an ego-dissolving experience. In ketamine-assisted psychotherapy, clients are given high doses — typically via intramuscular or intravenous administration — to induce a dissociative experience. People often experience traveling out of their bodies and losing touch with the physical realm, where they detach from any prior sense of identity.
Psychedelic therapy aims at the “transpersonal,” which is typically translated as “beyond the personal.” While content from one’s life may enter the non-ordinary field of awareness, it is also possible that abstract and symbolic content will take over, and that all recognizable forms will dissolve away. Moreso than a psycholytic session, a psychedelic ketamine experience is a “journey,” and it is typically powerful enough to shake up even the most stuck cognitive patterns, at least temporarily.
Naturally, such an experience can arouse fear. This is why having a therapist present is vital. The therapist provides support through intentional presence and, if needed, through direct intervention. The calm therapy office and the therapist’s presence provide a secure base from which to launch into the abstract space of a high-dose ketamine experience.
What Is Each Used For?
Ketamine-assisted psychotherapy is currently being used to treat a host of conditions including depression, addiction, and PTSD. Within these diagnoses, however, there is a range of manifestations of severity, and the severity impacts whether psychedelic or psycholytic treatment is the preferred option.
High-dose psychedelic sessions are often used for more extreme circumstances. The ego-dissolving experience is believed to help people who are deeply stuck in harmful patterns to quickly break free of their accustomed cognitive restraints. A primary example is suicidality. When people are actively suicidal, there is a sense of no escape. Hope has been lost, and suicide is seen as the only option.
People in such a place need something powerful to break free of such a powerfully confining mentality, and current treatments for depression, such as SSRIs, can take weeks to take effect (if they work at all). Psychedelic ketamine sessions can facilitate a sudden breakthrough, or at the very least an alleviation of symptoms that creates space for new modes of thinking.
(Note: A single ketamine session should not be mistaken as a “cure”; rather, it can open the potential for new ways of thinking and being, which are then enhanced through successive ketamine sessions and ongoing psychotherapy.)
Low-dose psycholytic sessions can be more effective with less severe manifestations of the aforementioned diagnoses, such as milder forms of depression. At the same time, lower doses are often recommended for clients with a significant trauma history, as a higher dose can bring up too much trauma and potentially overwhelm the client. With clients in such a dissociated state, therapists can do little more than harm reduction, and the potential for re-traumatization increases.
Low doses mitigate that risk. Since psycholytic clients can stay in contact with the therapist, they can also remain in deeper contact with their personal process. This allows for the client and therapist to work together to ensure that the engagement with the traumatic material remains within the client’s “window of tolerance,” or the zone of arousal in which a client can remain regulated and safe. If the window is being breached, psycholytic sessions allow for more agency to change the course and reconnect to a grounded place.
Finally, psycholytic sessions are also ideal for helping heal relational wounds. Harmful patterns, such as addiction, are often rooted in relational, attachment struggles, and the only way to heal such struggles is by being in relationship. The therapist assumes the role of the other in relationship, and the client is thereby given the opportunity to work though relational hangups in direct communication with the therapist. As low doses allow clients to stay in contact with the therapist, they are preferable for such treatment.
Conclusion
Both psychedelic and psycholytic ketamine-assisted psychotherapy have their place. Therapists must be attuned to clients’ specific needs, as well as sensitive to their medical and mental health history, in order to properly assess which modality, if either, is ideal. As is the case across the board in psychedelic-assisted psychotherapy, the medicine session is never a panacea or replacement for therapy. The lasting benefits of the non-ordinary experience comes through ongoing therapy and integration, regardless of whether a psychedelic or psycholytic dose was used.
