MAPS Bulletin Volume XVI Number 2: Autumn 2006

Editor‘s note: Just before this Bulletin went to print, National Institute of Mental Healthsponsored researchers published a study in the Archives of General Psychiatry finding that ketamine shows breakthrough potential as a treatment for major refractory depression. In this upcoming article, Dr. Hammerschlag describes a case study in which he utilized ketamine-assisted psychotherapy to help a patient work through difficult psychological material associated with advanced-stage cancer. MAPS will be exploring options for a ketamine/end-of-life pilot study, similar in design to three other studies in patients with anxiety associated with end-of-life issues: Dr. Peter Gasser’s MAPSsponsored study evaluating LSDassisted psychotherapy, Dr. John Halpern’s MAPS-initiated study evaluating MDMA-assisted psychotherapy, and Dr. Charles Grob’s Heffter-sponsored research investigating psilocybin-assisted psychotherapy. All this research may eventually lead to FDA approval of psychedelic psychotherapy in general for anxiety associated with end-of-life issues, with therapists and patients able to choose between different substances at different stages of the psychotherapeutic process.

Ketamine is a pre-anesthetic adjunct first manufactured in 1965. A Schedule III drug, ketamine has accepted medical uses and can be prescribed by physicians, dentists and veterinarians. It is a short-acting dissociative with some psychedelic-like characteristics. Ketamine poses minimal risk of cardiac and respiratory complications, although, unlike other psychedelics, it can lead to physical dependency if used regularly.

Ketamine induces a dissociative state that causes subjects to lose track of time and place, and to detach from awareness of external stimuli, including pain. Professionals in the treatment of alcoholism, anxiety disorders, and posttraumatic stress disorder (PTSD) have effectively used ketamine-assisted psychotherapy to treat patients. Before treating Steve, the patient described in this case report, I had never used ketamine-assisted therapy in my practice.

Steve was 64 years old when I first met him in October, 2004. Ten years earlier, he had been diagnosed with nonalcohol related cirrhosis. In early 2000 he was diagnosed with liver cancer, and two years later he learned that he had metastatic disease to the bone. At that point, his doctors told him that he had about 6-9 months to live. He had been treated by chemotherapy, surgery and radiation, but his cancer continued to progress. By the time I saw him, he was no longer eligible for a liver transplant.

However, Steve was unwilling to give up the idea that he could heal himself. He was searching for healing methods and not prsseparing for death. Steve believed that he had been a shaman in a previous life, and wanted to regress back in time to speak with his previous incarnation. Steve believed that, by accessing this ancient knowledge, he could learn to heal himself. To this end, he wanted to take peyote in a Native American healing ceremony, hoping that it would facilitate his vision.

Steve first contacted me at the recommendation of a friend, since I have experience in the sacramental use of peyote in Native American ceremonies. During this initial meeting I advised Steve to consider alternatives because peyote is irritating to the G.I. tract, and not dosespecific. Peyote use often causes vomiting, and if Steve vomited, he could bleed internally, which had already happened to him once. Steve and I talked and discussed alternatives that might be helpful, like hypnotherapy and past-life regression.

Steve and I had quite a bit in common and resonated with one another. We were both originally from New York City and had graduated from city high schools and colleges. Steve went on to law school, and became a distinguished attorney and later a federal judge. He had been married and divorced, with two grown children to whom he was close. Angry with doctors, he held them responsible for failing to diagnose sooner the extent of his metastatic disease. If they had found it earlier, he would have been eligible for a transplant. Despite his limited options, though, Steve was not ready to die.

Steve was rational, without evidence of thought disorder; moreover, he was an intelligent critical thinker with a quick wit. He described his spiritual life as ethnically Jewish, by which he meant he liked pastrami on rye and matzoh ball soup, but that he had no personal relationship with God, or any interest in developing one.

After our initial visit, Steve decided to explore hypnotherapy. During his second visit, he proved to be an easily inducible subject and was able to regress in time to Neanderthal days. At one point, Steve described seeing cavemen from afar, but felt reluctant to join them. I told him to open his hands, put them in front of himself, and approach them. He did so, and they made room around the fire. He sat down cross-legged in the circle but understood nothing they were saying. He did not speak to a shaman and was unable to go back any further in time.

When we talked about it later, he said he would love to go deeper into trance and asked if I could intensify the hypnotic experience. That’s when I told him about ketamine-assisted therapy, and explained that ketamine could be legally prescribed and had been used clinically in the treatment of posttraumatic stress disorders (PTSD) and chronic alcoholism. Used in controlled conditions, there is strong supporting evidence that it can be helpful in making healthful changes, since it activates a portion of the brain that makes it possible to move beyond ordinary conceptions of time and space. I told Steve that I had not yet used it in my clinical practice but was willing to try, if he wanted. I told him to review the literature and talk about it with his children. By the next visit, he had done his homework and had decided to try it.

Steve had experimented with psychedelics in the 1960s and wasn’t frightened at the prospect of working with them in a controlled setting. He only wanted to be sure that I would stay with him during the experience, and I told him that I wouldn’t leave him and would be totally involved. I wanted to speak to his children, so I met with his son, who happened to be a local physician, and he told me that both he and his sister were fine with whatever their father wanted to do. He added that it didn’t surprise him at all, and that he would provide the syringes and needles to cut his father’s expenses.