Ketamine-Assisted Psychotherapy for PTSD Related to Racial Discrimination

This case study of ketamine (4x) in combination with psychotherapy (mindfulness-based cognitive therapy, MBCT) describes how it was used to treat PTSD symptoms. The study shows initial success, but also remission at 6-month follow-up.

Abstract

“Current research suggests that ketamine-assisted psychotherapy has benefit for the treatment of mental disorders. We report on the results of ketamine-assisted intensive outpatient psychotherapeutic treatment of a client with treatment-resistant, posttraumatic stress disorder (PTSD) as a result of experiences of racism and childhood sexual abuse. The client’s presenting symptoms included hypervigilance, social avoidance, feelings of hopelessness, and intense recollections. These symptoms impacted all areas of daily functioning. Psychoeducation was provided on how untreated intergenerational trauma, compounded by additional traumatic experiences, potentiated the client’s experience of PTSD and subsequent maladaptive coping mechanisms. Ketamine was administered four times over a 13-day span as an off-label, adjunct to psychotherapy. Therapeutic interventions and orientations utilized were mindfulnessbased cognitive therapy (MBCT) and functional analytic psychotherapy (FAP). New skills were obtained in helping the client respond effectively to negative self-talk, catastrophic thinking, and feelings of helplessness. Treatment led to a significant reduction in symptoms after completion of the program, with gains maintained 4months post-treatment. This case study demonstrates the effective use of ketamine as an adjunct to psychotherapy in treatment-resistant PTSD.”

Authors: Mailae Halstead, Sara Reed, Robert Krause & Monnica T. Williams

Summary

A client with treatment-resistant PTSD was treated with ketamine four times over a 13-day span as an off-label, adjunct to psychotherapy. The client experienced a significant reduction in symptoms after completion of the program, with gains maintained 4 months post-treatment.

1. Theoretical and Research Basis for Treatment

Over the last decade, there has been a growing interest in psychedelic-assisted psychotherapy for the treatment of a variety of mental health conditions. Some medications have even been granted Breakthrough Therapy designation by the FDA.

Emphasis of Ketamine

Ketamine is a medication that has been found to alleviate depressive symptoms in treatment-resistant depressed patients within hours and may be sustained for up to 2 weeks. Ketamine is also one of the few medications recently granted Breakthrough Therapy designation as an off-label treatment for depression.

SSRIs are considered a first-line pharmacological treatment for PTSD, but response rates rarely exceed 60%, and less than 20% to 30% of patients achieve full remission. Ketamine may also be helpful for the treatment of PTSD, although fewer studies have examined ketamine-assisted psychotherapy.

Racial Trauma

Racial discrimination can have deleterious effects on the mental health of African Americans. Racial trauma can be caused by overt or covert actions carried out by individuals or society, and can result in PTSD.

Microaggressions are subtle forms of racism that can lead to trauma. They are also linked to discrimination and racial climates that can lead to PTSD symptoms.

Basis for Treatment

There is evidence that psychedelic-assisted psychotherapy can help with the treatment of PTSD, but most participants in studies are non-Hispanic White. Additionally, Black communities are disproportionately arrested and incarcerated for non-violent drug offenses, which could further lead to mistrust toward therapeutically consuming substances deemed illicit.

Third wave CBT approaches such as Functional Analytic Psychotherapy (FAP) may be well-suited for psychedelic psychotherapy, particularly for people of color. FAP promotes intrapersonal awareness as well as interpersonal awareness between the client and therapist, encouraging a strong and authentic connection.

Mindfulness promotes mental wellbeing by changing the relationship individuals have with their thoughts. Mindfulness-Based Cognitive Therapy (MBCT) has been used successfully to treat PTSD in women of color, but has not yet been examined for its utility in treating racial trauma.

2. Case Introduction

Robyn, a 58-year-old African American woman, was self-referred after going on disability following experiences of race-based discrimination in the workplace. She had complex PTSD, Persistent Depressive Disorder, and was ready to explore the option of ketamine-assisted psychotherapy.

3. Presenting Complaints

When beginning treatment, Robyn was isolative and struggled to make trips to the grocery store because she was afraid she would experience further acts of discrimination. She also struggled with severe anticipatory anxiety and felt that she did not have any close platonic friendships.

4. History

Robyn had a challenging upbringing filled with abuse and neglect. She was often called racial epithets and assaulted at school, but no one ever intervened until her front teeth were knocked out.

Robyn pursued treatment for PTSD much later in life, and was officially diagnosed with PTSD in 2003. She has since tried several treatment modalities, including DBT and anti-anxiety medications, but her PTSD symptoms returned when she was re-traumatized at work.

5. Assessment

A structured clinical interview, the UConn Racial/Ethnic Stress and Trauma Survey, a self-report measure of depressive symptoms, a self-report measure of negative cognitions about self, the world, and self-blame, and a cultural genogram are used to assess psychiatric disorders and racial trauma.

Robyn experienced symptoms of a pervasive sense of hopelessness, insomnia, agitation, and loss of enjoyment in almost all areas of her life. She met criteria for both PTSD and MDD.

6. Case Conceptualization

Robyn’s symptoms were conceptualized through a culturally-informed model of PTSD, which considered her unique social background and how her early negative self-concept was exacerbated by the subsequent work-related discrimination she endured.

Robyn’s therapists used an eclectic approach to treatment, guided by several empirically supported therapeutic orientations. They used FAP and MBCT to address the many experiences that Robyn reported, and validated and provided compassion for her experiences.

7. Course of Treatment and Assessment of Progress

Robyn worked with a diverse therapist team, including a Black woman, a multiracial woman, a White man, and an African American female Clinical Psychologist.

Robyn met with her two therapists and the prescribing clinician over a 13-day period for both drug and non-drug treatment. She received 150 mg of ketamine sublingually on 4 days of the IOP treatment, and completed cognitive restructuring, MBCT and various FAP techniques during integration sessions.

Pre-Treatment Sessions

Robyn completed a series of assessments to determine initial eligibility for treatment. She reported high suicidality and a safety plan with her local therapist, but no current plan or intent.

Preparatory Sessions

Therapists began Robyn’s treatment by going over the informed consent form in detail, highlighting current ketamine therapy research, the subjective effects of ketamine, expectations of dosing sessions, and the ongoing process of consent to treatment. Robyn expressed some anxiety about the dosing sessions, but was overall optimistic and motivated to begin treatment.

Therapists used ethnocultural genograms to understand how Robyn’s multiple traumas still impacted her beliefs about herself, the world, and her current relationships. They were able to identify distorted views about ethnic identity, dysfunctional interpersonal relationships, and internalized feelings of anger, fear, and shame.

After obtaining relevant clinical information and developing goals, therapists provided psychoeducation on various grounding and self-regulation techniques, and suggested that Robyn develop an “intention” to help her stay with difficult emotional processes. Robyn was also instructed to complete a daily ABCD log to address core beliefs.

First Dosing Session

Therapists arrived at the prescriber’s office 30 mins prior to the session start time to help set the space, check in about the dosing session, and greet the client. The client courageously took the lozenges, holding them in her mouth for 10 mins before swallowing.

During the onset medication effects, Robyn reported feeling relaxed, but also a desire to work, to heal her deepest wounds. She stayed with the relaxed feeling and processed past traumas and wounds from her relationships with her mother, father, daughter, and eldest brother.

Robyn realized that self-critique was one way she learned to distract herself from experiencing pain. She also discussed experiences of racialized trauma and fears of disclosing the harms that happened to her.

Robyn shared that her partner made dismissive comments about treatment and culture the night before, which led to an argument. She decided to proceed with treatment with minimal contact with him.

Integration

Robyn expressed some lingering anxiety over the next few days, but was able to sit with the discomfort by repeating the affirmation, “I am safe”. She also described a new way of being present with sadness.

Robyn continued to integrate and develop healing practices around her somatic manifestations of trauma, including self-regulation techniques, awareness of her trauma responses, and a cognitive shift in how she conceptualized her experience of early childhood abuse.

Robyn was guided through a meditation focusing on “hard emotions” and sources of anger, and then instructed to create an object of anger with the use of air-drying clay. Robyn felt empowered to be able to create something that was praised and would not be destroyed.

During the first integration sessions, Robyn’s therapists integrated mindfulness exercises with various CBT skills such as Socratic questioning, cognitive restructuring, and various progressive relaxation interventions.

Second Dosing Session

Robyn’s dosing session was very difficult as she made contact with some of her most painful traumatic memories. She used self-regulation techniques and Internal Family Systems interventions to help her move through the painful content and not get stuck. Therapists used the IFS technique of “Multiplicity of parts” to help Robyn compartmentalize and cope with the emotional injuries from her past, and she reported no further suicidal ideation.

Integration

A series of integration sessions included Robyn processing past challenges of cross-racial dynamics, in both personal and professional spaces. Robyn was able to successfully use a positive affirmation to not enact old coping mechanisms after experiencing a microaggression at a hotel.

Robyn discussed her trauma history with her therapists, and how she had developed a conditioning around white people. Her therapists enlisted a White therapist to discuss his experiences with White privilege, and Robyn integrated the insights well and reported a decrease in anxiety and depression symptoms.

Third Dosing

Robyn began to harness a deeper presence within her body and trust in herself to process through emotional experiences. She gained clarity on her career and began to understand the survival behaviors she developed that no longer served her.

Robyn was able to identify moments that negatively impacted her, and also recognize she deserved better. She also expressed fears with regard to work and how people will treat her, but she knew her stuff, so they couldn’t fire her.

Robyn began to find acceptance and compassion for herself, and accessed memories of having fun and being free from oppression. She began exploring alternative work options after the ketamine effects wore off.

Integration

Robyn presented to therapy with mild anxiety, but described feeling more proficient in using various coping skills to stay with the discomfort until it passed. She described feeling her anxiety turn to anger, and shared that exercising served as a healthy outlet for managing anger.

Robyn’s successful use of coping skills led to her applying for new jobs in a new geographic location. She was able to acknowledge that reentering her previous toxic work environment had potential for additional harm, and that she had a variety of options in terms of seeking new employment.

Fourth Dosing

Robyn’s intention for this dosing session included deepening her awareness of herself and beginning to recognize her power. She experienced a sensation of being pulled through time and talked about her fears about facing additional trauma and the exhaustion she felt as a Black woman existing in oppressive spaces.

Robyn discussed possibilities of starting a new life, a new job, and developing new relationships. She described feeling confident in taking risks and navigating unmarked trails, and ended the session by describing how it feels good to trust herself.

Integration and Assessment

During these sessions, Robyn continued consolidating the gains she made over the past 13 days and learned new CBT skills, breathing techniques, and additional therapeutic tools. She hopes to apply these skills in the workplace.

Robyn reported that she had successfully maneuvered her behavioral responses despite her fears, and she felt her bigger area of opportunity was working on her negative self-talk through reframing.

Outcomes

Robyn’s anxiety and depression decreased significantly in the 2-week span of treatment, and she experienced an improvement in her sleep. Her depression symptoms decreased to a sub-clinical range as measured by the BDI-II, and she experienced a 1-point decrease in her PTCI score at the 6-month follow up session.

8. Complicating Factors

It takes presence, patience, and skill among therapists to work with clients in altered states of consciousness who experience suicidal thoughts. Make sure your de-escalation tools are culturally appropriate, encourage clients to stay with the feeling versus fusing with the thoughts, and complete a risk assessment and safety plan.

Robyn made tremendous gains during her time in treatment, but she still experienced acts of racism. She struggled with spending time in public spaces due to fears of discrimination.

9. Access and Barriers to Care

African Americans experience high rates of discrimination and may feel hopeless in finding a clinician who understands these issues or finding relief from the mental health sequalae of racism.

Robyn’s PTSD symptoms had increased so greatly that she could no longer work. She had to travel across state lines to obtain quality treatment, and the KAP sessions were spaced closer together than some approaches that may provide more time between sessions for integration work.

10. Follow-Up

Robyn had triadic follow-up sessions with her clinician at 2-weeks, 3-months, and 6-months. She also continued to see a therapist at home, but discontinued therapy after 2-months.

Two-Week Follow Up

Robyn reported successfully implementing interventions for anxiety, negative self-talk, and emotional self-regulation, and received an invitation for a second and third interview with the company she applied for while in treatment.

Robyn continued to experience the positive effects from the KAP-IOP, including increased awareness around her behaviors, increased meditative practices, and a decrease in her fear of starting a new job.

Three-Month Follow Up

At the 3-month follow up, Robyn had gotten the job she applied for, was putting her home on the market, and was no longer in a relationship with her previous partner. She began attending various “MeetUps” in the surrounding area.

Six-Month Follow Up

After starting a new job in a new state, Robyn experienced an increase in depressive symptoms. A supplementary ketamine dosing session was conducted, during which Robyn experienced several affirming experiences and made statements such as, “I can feel happiness coming out of my chest!”

11. Treatment Implications of the Case

Robyn’s initial treatment of depression and PTSD with ketamine-assisted psychotherapy was successful, and she was able to regain functioning in all domains of her life.

12. Recommendations to Clinicians and Students

Robyn’s case includes several important considerations surrounding the experience of racialization, psychedelic medication, and trauma. Therapists should approach clients who have experienced discrimination with openness, curiosity, and maintain cultural humility.

A qualified medical professional should evaluate all clients considering ketamine-assisted psychotherapy before beginning treatment. Clients with severe dissociation in PTSD should be treated with care and caution, and alternative treatment options should be readily available.

Robyn’s case was unique in that she did not go home or to her partner’s house for 2 weeks during her IOP. Her partner’s criticisms could have changed her trajectory.

Robyn’s treatment consisted of 16 hr of dosing sessions and 24 hr of integration/ preparatory sessions across a 2-week period. The treatment was successful because the therapy was completed within a culturally attuned container/framework.