"I feel like I'm being gently dissected by multicolored planes of light"
"Do patience and the desire for novelty sit in opposition with one another?"
"What time is it? Really?!?"
Recently I had the opportunity to play the role of client at Asheville Integrative Psychiatry for a therapist who was finishing their training in Ketamine Assisted Psychotherapy combined with nature connection. Both as a physician who wants an accurate understanding of what it is that we are offering our patients, and as an individual who sees value in occasionally twiddling the knobs of perception, I found this experience useful and unique.
I'd like to share my experience but I need to acknowledge a couple of important caveats. First, I am not currently suffering from a known mental illness, plagued by intrusive thoughts, or amidst a transitional crisis in life. These unwanted states of being are the primary reasons we use ketamine assisted psychotherapy (KAP) and there is little evidence that KAP is inherently valuable in the context of just trying it for curiosity's sake. For the record, I am a middle-aged, cis-gendered, white, male, emergency room physician with two children and, outside of the stresses of my profession, have been extraordinarily fortunate in my life with regards to mental heath and trauma. Second, I have had prior experiences with recreational psychedelics that have been both good and bad. I do not, however, endorse the use of recreational psychedelic medicines for the sake of treating mental health conditions. Psychedelic medicines used without therapeutic and medical guidance can be dangerous and destabilizing, particularly for those in crisis. Lastly, I am one of the two owners of Asheville Integrative Psychiatry and my role there is making sure that our medical protocols are safe. I do not participate in psychiatry or therapy. I also do trail work and hornet removal. I am very biased toward the work that we do there and want to acknowledge that plainly. I think we do good work and take good care of our clients.
Over the last 20 years, it is clear that the use of psychedelics has become increasingly prevalent and acceptable in our country. Between working as a river guide and spending a lot of time at transformational festivals, I have been around the use of many different psychedelics for most of my adult life. In the last several years, I have seen increased use of recreational ketamine in various social circles. And while there are aspects of this trend that I celebrate, I am also growing increasingly concerned that we have failed to learn an important lesson from indigenous cultures and from our own cultural experiments in the late 60s. Primarily, we continue to see the drug or medicine as the most important determinant of the experience and often fail to give appropriate consideration to our own mindset, our intentions, and how we plan to translate the psychedelic experience into meaningful change once we have returned to an ordinary state of consciousness. An unplanned psychedelic experience without context or a plan for integrating the experience is another form of being drunk, albeit with a slightly more existential hangover.
Tiffany Sauls MD, psychiatrist, at Asheville Integrative Psychiatry
With this in mind, the therapy-assisted component of KAP intrigued me as much or more than the effects of the medicine itself. How would a trained therapist guide me into and out of the psychedelic space and what would it be like to have a trained guide for the experience? I met with my therapist, Derek, in the log cabin at Asheville Integrative Psychiatry and found the view of the surrounding forest and mountains more relaxing than a typical doctors office but I also was experiencing some anxiety about meeting with a therapist. While I enjoy writing about experiences, talking to strangers about myself and my innermost thoughts gives me a bit of fight or flight response. Although Derek was finishing up his training in our specific approach to KAP, he has extensive experience in various modalities of therapy and is MAPS trained in psychedelic therapy so I knew I would be in good hands.
Honestly, after my initial anxiety, the hour long preparatory session was enjoyable and very useful. I do not have much experience with therapy and having someone ask me thoughtful questions and reflect carefully on my answers felt like a psychological embrace. I am hesitant to make this piece overly personal, but my career in emergency medicine has given me some experiences that I will cherish forever and also some experiences that I will never understand. An aspect of emergency medicine that may not be immediately apparent is the way it resembles a very poorly edited film. You walk out of a room where you have been exposed to incomprehensible suffering and loss and walk straight into a room where someone is angry that they have had to wait so long to have their ingrown toenail removed. Often there is no time to process any significant experience until something reminds you of it, and after 20 years, it sometimes feels like there are parts of my mind littered with landmines of unprocessed traumatic experiences. I have not discussed this with many people but talking to Derek about it felt safe and easy. His skills at reflecting what I was saying and framing it in ways that I had not considered were immensely valuable and these were insights that were unrelated to a psychedelic experience.
For clients who do not have a strong or current connection to nature, the process at Asheville Integrative Psychiatry begins with nature connection work. I had spent the morning doing trail work by myself in the forest and was headed to Linville Gorge to camp after my ketamine session. Derek and I discussed ways that I could use my time in the gorge to integrate the experience I was about to have. The hypothesis at Asheville Integrative Psychiatry is that a strong connection to nature nourishes the inner healer that we all possess. Feeling connected with natural surroundings also serves as an anchor during the potentially stormy experience of psychedelia. If connecting to nature is part of the process of integrating a psychedelic experience, then that experience becomes easier to access in day to day life for continued healing.
On site at Asheville Integrative Psychiatry
The next day was a cool, but sunny, late fall day with the slow, steady spin of the the remaining leaves animating the increasingly bare trees. The calls of noisy crows were echoing up the steep watershed that surrounds Asheville Integrative Psychiatry. I had chosen to have my ketamine session in The Shed, a former outbuilding-turned-treatment-space and named for the long snake skins that were found there during its renovation. With the windows and doors open, the space feels simultaneously sheltered and connected to its surroundings. It is decorated with objects found in nature and painted in soothing shades of green. There are 5 silver birch trees cut from a friend's farm in Kentucky, that form columns around the tiny room. There is a low reclining lounge chair for clients in the center of a circular woven rug. There is an excellent sound system for therapists who incorporate music into the experience. Per the psychiatrist's recommendation, I had avoided alcohol for several days and fasted that morning. I felt excited, nervous, and very self-conscious. I was raised in Kentucky by a family that places a lot of value on self-reliance. Discussing thoughts and feelings with a therapist would probably seem stranger to my family than the use of psychedelic medicines.
There are a variety of ways to use ketamine; oral, nasal, intramuscular, and intravenous. Each has its advantages and drawbacks and the decision of which form to use is typically made by the psychiatrist and nurse practitioner who do the medical monitoring for the sessions. I would be using oral dissolving lozenges and, based on my size and prior experience with psychedelics, the psychiatrist suggested starting with 300mg. Before beginning, I met with the psychiatrist to check my vital signs and review expectations surrounding the intensity and duration of the experience. With the smell of burning sage drifting through the space, we all took a moment of silence to listen to the forest around us and focus on our breath and intentions. I picked a "scorpion" card from an animal tarot deck that felt synchronistic given that the evening's full moon was the official end of scorpio and I would be camping with my close scorpio pal. Burning sage and talking tarot cards is certainly something I have never done with a medical professional in the past.
Oral ketamine, despite the pharmacist's best intentions with flavoring, is not a savory treat to look forward to, but is certainly no worse than dried mushrooms and its flavor reminded me of cheap halloween candy. Trick or treat, indeed. The onset of oral ketamine is fairly rapid and, within 15 minutes, I began to feel pleasantly light headed and relaxed in my body. Ketamine is described in medical literature as a dissociative anesthetic and I have used it many times in the emergency room, at sedative dosages, to safely sedate patients for otherwise painful procedures. In this setting we were using a fraction of that dosage but the feeling of dissociation was evident, and my sense of self felt less attached to bodily sensations.
Psychedelic experiences are, by nature, ineffable and impossible to translate easily into a narrative. It felt best to have my eyes closed. Eye shades were available but I did not like having something touching my face. With my eyes closed, I was immersed in the experience of sound. I felt the connections between my mind and body as energetic waves as the music pulled me into itself. Sounds were translated to lights and shapes as I was transported along the melodies and rhythms through an internal landscape. I did not feel any fear or anxiety as I have with other psychedelic experiences but I do not know if that was due to properties of ketamine or the presence of a therapist and the planning put into the experience. I heard outside birdsong intermingled with the rhythmic music. Derek occasionally asked me to pay attention to my breath and to connect with my body or reflected on statements that I made. I was aware of his presence but did not feel self-conscious because of it. He appeared to be meditating but present, and it was comforting to know that I was free to explore the psychedelic terrain without worrying about what was happening around me or feeling responsible for others.
As the crest of psychedelia washed over me and began to recede, I felt strangely cleansed, as if the connections between my mind and body had been serviced by some psychic root-rooter technician. I felt joy and gratitude at how well my senses and limbs functioned, perceiving the beauty around me and translating it into meaningful information. I felt gentle and calm. Derek asked me occasional questions as I returned to a more analytical mindset but continued to encourage me to stay connected to what feelings these thoughts were creating within my body, a skill that I am unpracticed at. Derek encourage me not to narrate my experience or try too hard to "explain" it. He recommend letting it unfold over the next few days and just seeing what I noticed internally. The experience lasted between 2-3 hours and at 2 and a half hours I felt normal enough to walk around outside and have a snack. I tolerate psychedelics much better than I tolerate fasting and some food really helped me transition back into daily life.
That evening I felt tired and, for maybe the first time in a decade, had a powerful craving for hot chocolate. I felt a little slow when I was trying to pack for camping but managed to do so without forgetting anything important. I would have probably preferred just sitting around and going to bed early but I wanted to get an early start on our hike into Linville Gorge the next day. I slept well and woke up feeling like myself but with a somewhat indescribable feeling of having had my nerves enjoyably cleaned and waxed.
Author, Linville Gorge, from Shortoff Mountain
I do think that being able to spend the next 36 or so hours outside in a beautiful place with a close friend was extraordinarily valuable. Without the distractions of daily life, I was able to hold the KAP experience in my mind while being exposed to the millions of interwoven miracles that make up a forest. We had two river crossings early in the day while temperatures were still near freezing which certainly helped me be "in my body". Many of the poplar trees retained yellow leaves, giving the trails a warm golden light despite the cool temperatures. By lunchtime, there was enough warmth to lay in the sun comfortably and, while my friend Thomas scared away some fish with his fishing pole, I took a nap in the leaves to the sound of running water. I do not recall the last time I took a nap, maybe in the mid-90s. In general I felt relaxed and energetic, if a little unfocused. Often, however, I tend to be too focused, so it was not an unwanted sensation.
I followed up with Derek for my integration session after returning home from camping. Based on that conversation and taking some time to reflect on the experience in general, I cannot say if the ketamine experience remodeled my internal landscape with regards to some of the difficult experiences I have had in the emergency room. But, I do think that it lead me to see them differently. I have had this this reframing experience explained to me from KAP patients in the past. A medicine that offers a new perspective is a fascinating thing when used by a trained and experienced team of healers.
In the days following the KAP session and camping I have seen some of my experiences less as damage and more as a form of weathering. I have always seen beauty in the way that wind, water, and time shape natural elements in the landscape. I see that beauty as a result of a dynamic balance between internal structure and external forces and less of a struggle between opposing tendencies. Something about this balance makes me see patience, less as a fought-for skill, and more as the only reasonable option.
Typically, clients would continue to have KAP sessions weekly with therapy before, during and after their KAP sessions for 4-6 weeks. Research has shown that this approach can create long lasting effects. At Asheville Integrative Psychiatry this approach is combined with guided nature connection in ways that promote continued healing without continued treatment. Having done only one session, I cannot speak to the experience of having completed our 6 week protocol.
Compared with other psychedelic experiences that I have had, I can attest to the profound difference that a qualified therapist can create. Without Derek's thoughtful questions and reflections, it would have been an interesting and memorable experience but neither transformative nor insightful. The psychedelic experience has been described as "softening the clay of the mind" and I think that the ketamine made me more capable of internalizing the insights that I had gained from the therapist. I also really appreciated that nap by the river. Sleeping in the sun next to the sound of a river does the body and soul some good.
I think it is easy for most people to see how a well trained therapist and a healthy connection to nature can be good for healing and growth. What, then, is the purpose of adding psychedelic medicines to this combination? My opinion, based on this experience, is that ketamine can produce a change in perspective that allows us to act on new insights more easily than we otherwise could in our default state of mind. Sometimes our habits of thought make it very difficult to create new behaviors. I think that ketamine can decrease unwanted recurrent thoughts and allow new patterns of thought to be formed. I have heard it described as "shaking the etch-a-sketch" and I think that is a good analogy.
And to those noisy crows that had so much to say amidst my psychedelic experience, I want to say thanks for the reminder to listen and laugh. You guys have it down.
Josh Short MD
Asheville Integrative Psychiatry
Upper Creek Falls