Manuela Joannou M.D. CCFP (EM) FCFP, Markus Besemann CD1, B.Sc., MD, FRCP(C), Julie Beaulac PhD, Mary Marcolin MACP RP

ABSTRACT 

This paper aims to capture the first-hand accounts of first responders, military members, and veterans who participated in a novel residential group-based ketamine assisted psychotherapy program (KAPP). Participants were mostly those with severe PTSD and treatment resistant depression, often with drug and alcohol addiction or misuse, many of whom had had one or more previous suicide attempts. Observations from family members and their primary mental health providers are included as well.

INTRODUCTION

Our society relies on competent emergency services, (including medical services), and military to respond to threats and adversity. Military members, police officers, firefighters, paramedics, physicians and nurses are subjected to many critical incidents throughout their working life.

These incidents can take a cumulative toll on their psychological wellbeing.¹ It is known that exposure to stress is often the root cause of many affective disorders including depression, anxiety, post traumatic stress disorder (PTSD), moral injury, and addictions.^1,2,3 Having significant numbers of members impacted or removed from active duty due to Operational Stress injuries and their sequelae presents challenges in service effectiveness, safety, and staffing.⁴

There has been a recent resurgence of interest in the use of psychedelics in treating refractory depression, suicidal ideation, PTSD and addictions.^1,2,5 Use of transformational doses of ketamine, the only legal dissociative/psychedelic in Canada,⁶ has been shown to quickly dissipate suicidal thoughts and symptoms of PTSD, anxiety, and depression.^1,2,5,7,8 We have found that combining the benefits of group therapy with a transformational ketamine journey can quickly reduce symptoms of Operational Stress injury. Our professional team includes military and emergency medicine physicians, psychiatrists, psychologists, psychotherapists and peer mentors. Applicants are screened for both medical and psychiatric suitability for ketamine administration. In our group ketamine assisted psychotherapy retreat program, we first administer a lower, “relational” dose of ketamine to help bond the group and build trust. This affords an opportunity for developing an optimum mindset which is then enhanced with group psychoeducation and therapy presenting new concepts and perspectives.^9,10 Administration of a higher, transformational dose of ketamine follows in the next few days. The focus is then on group-based integration and processing with the aim to capture new perspectives, intentions and paradigms that can be applied immediately and into the future. We have found that the effect of the ketamine very often allows a person to get clarity regarding a more precise nature of their psychological wounds. This allows opportunity for addressing the pain of the wounds in a direct manner, so that self soothing with alcohol or drugs is no longer as compelling. It also appears at times that ketamine being administered on only one or two sessions seems to mitigate withdrawal symptoms from cannabis and possibly alcohol as well. We would like to contribute to more research on this.

Our team has gathered some first-person accounts and observations from family members and mental health care providers of our participants that show the perceived impacts of the

treatments. We have enrolled more than 80 individuals over the past 16 months with no reported adverse outcomes.

First person reports

 

“After seeing the horror of war torn countries I was diagnosed with PTSD and was medically released from the military in 2015. I have been struggling with my life post military. I’ve been through in-patient programs in hospitals where numerous ECT treatments were administered, I’ve tried everything I could that would help me feel normal again. In June 2022 the pain and guilt were too much for me to fight through and I tried to take my life. After recovering in hospital I went for ketamine treatment. After the first dose I recovered and felt as though so much was lifted off my chest and I was as calm as I can ever remember. The despair and hopelessness I was going through vanished and I was able to focus on my recovery and start to heal with my family. The anger became more manageable, and I was so much less agitated.

Ketamine has allowed me to feel loved again and has lifted the darkness, I have no more thoughts of ending my life and I am able to focus on what’s really important.”

“In 2020 I was diagnosed with Major Depressive Disorder, Anxiety, and PTSD which left me contemplating taking my own life. The ketamine challenged my expectations and disassociated me from the part of my mind that always needs to control. I was being pulled through a series of metaphoric deaths and rebirths, emphasized with many colours and pressures within my body. I only felt love and peace, no fear. Afterward, I felt cleansed and so much lighter. Since the treatment, I have carried a deep sense of joy and peace that I didn’t think would live within me again and overall, I feel calmer with greater clarity. Worry no longer consumes me and I find myself more present in the moment.”

“Prior to my ketamine therapy, I was sleeping in the basement and quite certain that I would be dealing with divorce in the near future. I was depressed and filled with anxiety. I was escaping into video games for long periods of time. I was irritable and quick to anger. With the ketamine, I got to experience the pain and anguish I had put my wife through. This changed me at my core level. Since I’ve come home, I’ve earned my way back into the marriage with my wife. Our intimacy is higher than it’s ever been. I don’t have an urge or need to play video games. I genuinely just want to soak up my wife’s company.”

“I have found that my ability to focus and concentrate on abstract concepts and ideas has improved greatly. My PTSD had made my mind feel jumbled and I could not keep a train of thought. My mind has not been able to be this focussed since before my son’s death seven years ago. The internal shaking that I had in my chest, the tremors I had in my hands have gone and have not returned.”

“My emotional pathways have changed. I am now making much better decisions. The ketamine seems to have broken a barrier. I have more honesty with myself, and with others. I keep having little epiphanies about how I lived my life; things are much clearer. I had a definite food addiction. It has helped with that in a big way.”

“I was full of anxiety and depression. I wasn’t sleeping, I had no answers, nor did I even have good questions. I was isolated from many friendships and my family. In my psychedelic experience, I had run the gamut of emotions from joy to sadness, life and death, fear and excitement and had noticed that the emotions that I feel in transition from all of these places to another are all basically the same: anxiety, uncertainty, and fear. The experience showed me that those emotions were wasted because they didn’t stop the transition, they did not assist me in

 

the transition, and therefore were useless emotions to stress about. I feel as though about 80% of my crushing depression has been lifted from learning this very simple fact. I’m staring down the barrel of some really big domestic life changes that I need to make which normally would frighten the heck out of me, but for some reason my mind and purpose is much clearer.”

“The experience/treatment provided a fundamental shift in my approach to life that I wasn’t expecting. It has given me clarity and calmness. Since my initial treatment 10 months ago, I have been free of my need to use Cannabis. And after many years of using Cannabis, I finally feel free and in control. I am now able to focus on each moment and be present.”

“Since I had my ketamine treatment, I have felt very calm & happy. I have not felt the need to drink alcohol which has always been my go-to for everything. Happy, sad, angry, confused, red wine was my fix. Not just a glass or two, usually a bottle or more, almost every day. I know I have a drinking problem and have never had the strength to do anything about it. It has been 21 days and I’ve had 1 glass of wine and I didn’t even enjoy it. Something in me has changed since I had my ketamine treatment and it’s a change I’ve been waiting for years

Reports from families and spouses

“Dear Mom, I can’t believe how you have changed and recovered in the past year. You are so much happier, so much more open to sharing your story and I feel closer to you since you have been recovering. It’s almost like someone has restored the light in you. Having you come back a whole lot better helped me to get out of my dark place because it gave me motivation to keep pushing through and get into a better headspace. I am so grateful you are out of that dark place and still in my life.”

“I find a really big difference in my wife’s mood. She is happier, more cheerful. She is sleeping better and has less night terrors. Her anxiety is decreased. She takes better care of herself and takes time to rest when she needs it.”

“After my spouse completed her treatment, I noticed her anxiety was less. Specifically, she is able to see her anxiety coming on and be pre-emptive”.

“We are coming to my husband’s one year anniversary from his initial treatment, and our lives have been greatly impacted. This positive impact has been life changing for our entire family. Before, my husband was quick to anger, and rather be alone than with the family. He is now consistently involved in every aspect of my life and our children’s lives. He is present, both physically and mentally. It is such a great change that I enjoy every single day”.

Observations from mental health professionals

“I have been practicing trauma therapy for over 10 years and I have yet to see clients identify trauma targets as quickly as I have witnessed them do so via ketamine treatment. I have also heard clients describe, post ketamine treatment, that they have little to no depression, increased motivation and decreased use of alcohol and cannabis consumption in the following months.”

“In all participants, I observed a softening and opening to connection and a significant increase in authentic expression of experience. For instance, in one participant, her hat and layers of extra clothing came off and she allowed tears and feelings to be expressed, where initially there had been a strong defense of sarcasm. In another participant, she acknowledged drug use and the hurt that this has caused to her family and a desire to change.”

“Despite years of counselling, concentration and focus was still a significant issue for my client and disorganization of thought was acute. He would often complain of feeling “scattered”, struggling to keep a conversation or a clear line of reasoning. Cognitive functional disabilities were apparent. When anxiety escalated, he would quickly decompensate, becoming dissociative.

Following Ketamine treatment, it was as if he engaged me for the first time. He demonstrated eye contact, appropriate affect, responsiveness to questions and could follow a path of reasoning. He initiated communication and did not become “dreamy” when stressful subjects arose. This has allowed us to assist him with CBT and gradual exposures. Overall, we have seen a significant change in his ability to operate cognitive skill sets in a more adaptive manner.”

“My client was able to unburden himself of guilt and shame with new perspectives reinforced within the safe container of a group experience. With ketamine treatment, my client achieved milestones which could take years of talk therapy alone. Therapeutic sessions following ketamine have been very productive and ten months after treatment I continue to see remarkable improvement in my client’s life quality.”

Conclusion

In summary, we are finding that ketamine can be safely administered in a group-based psychotherapy program. This appears to quickly mitigate the symptoms of depression, suicidal ideation, anxiety, PTSD and moral injury in military members, veterans and first responders. The synergy of combining ketamine and group psychotherapy represents a potential untapped treatment for operational stress injuries.^3,9 This treatment could have significant impacts on quality of life and relationships for these individuals, as well as on disability management for military and first responder organizations.

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