Matthew Perry is in the news again this week.

A professional’s reflections on the safety of Ketamine-Assisted Psychotherapy.

A real psychedelic assisted psychotherapy case, ketamine treatment, and my thoughts.

Signi Goldman, M.D.

When Robert came to me seeking psychedelic-assisted psychotherapy using ketamine, he was disabled by fear. A 56-year-old lawyer and father, Robert was trying to function at home and at work with a debilitating level of anxiety. As he shared his story during the assessment process, I learned that Robert was a survivor of multiple forms of childhood abuse. And as we got to know each other during our “preparation phase”, it became clear that although the results of physical abuse were apparent to him, the emotional and psychological abuse had shaped him in ways he hadn’t yet realized. That abuse had created a lens through which he saw a distorted version of himself. We created a plan to explore this, using psychedelic doses of ketamine, supported by psychotherapy before, during, and after each dose.

The public is increasingly aware of IV ketamine infusions as a legal, and often effective, treatment for depression. But there is a second legal use of ketamine for mental health treatment, one the public is less aware of: intentionally using its psychedelic effects to enhance progress in psychotherapy.  This more intensive modality, Ketamine Assisted Psychotherapy, or KAP, is a very different model than the more widely known infusion therapy and is increasingly being offered in clinics around the country. KAP, done correctly, involves a thorough psychiatric and medical evaluation, an extended period of preparatory psychotherapy sessions with a specialist, and psychotherapy support during each psychedelic experience.  Follow up “integration” sessions are then used to process the content of each psychedelic session, and to support the patient on an ongoing basis as long as needed afterwards.

As we began the psychedelic work, Robert’s sense of having a “false self” showed up immediately in his ketamine sessions. He had always thought of himself as a likable and funny person, who put others’ needsbefore his own. As he told me afterwards, his psychedelic sessions helped him realize the following:

“I was the guy who was brought up by controlling parents…so, I built that—what do you call it?—that armor. That armor that I put on was to protect me. The humor that I used, and the self-deprecation, was to protect me—and to keep people at a distance”. 

It became clear that maintaining a people-pleasing “mask” was exhausting to Robert, and it was driving the anxiety he experienced when trying to relate to his family or coworkers. During his psychedelic sessions, we used his altered state of perception to help him examine the “armor” he was carrying, and to help him understand it better. One of his first insights, voiced by Robert himself during a ketamine session, was that his armor created a barrier to intimacy. At the same time, though, the armor also kept him safe from vulnerability. It made sense that it was there. And it also made sense that it needed to go for him to heal.

While Robert was in the psychedelic state, I invited him to describe what the armor was made of, and he took some time to reflect. 

“It’s made of my negative self-talk”, he said.

Robert saw, in his altered state of perception, that the shell of armor around his authentic self was made up of all the negative voices of his youth—that he was small, worthless, inadequate, and powerless. That he wasn’t enough. Wasn’t lovable. That there was something wrong with him. He also saw that the shell controlled his behavior by making him behave in ingratiating and pacifying ways, even when it harmed him. This was new information. In his ordinary state of awareness, he had been unable to see this.

As with any new approach to delivering wellness, the conversation around psychedelics, ketamine included, has its fair share of controversies, fervent enthusiasts, and worried detractors, and the media narrative has often swung between reverent enthusiasm and alarmist safety warnings.  Millions of words have been written about the burgeoning Psychedelic-Assisted Psychotherapy industry. And a great deal has happened in recent years, including actor Matthew Perry’s tragic death in 2023 from an overdose on ketamine and other substances, followed more recently by the FDA’s widely publicized decision to deny approval for the clinical use of MDMA, another psychedelic-like substance, pending further safety data. 

The very concept of psychedelic states for healing has its own dilemmas. We see public voices who are loud psychedelic advocates, with many enthusiasts touting recreational use, rather than legal, clinical use. Well-known podcasters act as cheerleaders for their illegal drug of choice, often consumed in dangerous ways. There are also public voices who are very against psychedelics used in therapy, pointing to publicized cases of harm as proof of inherent danger. 

Sometimes, what’s lost in the dialogue is the perspective of mental health providers who are advocating for careful, science-based, and ethical use in safe, monitored clinical settings. As a physician deeply steeped in this work, allow me to provide some needed context.

Those of us working and teaching in the burgeoning field of Ketamine-Assisted Psychotherapy have long known that the press coverage encouraged an overblown enthusiasm about psychedelics, one that was supported by some of the researchers, popular authors, patient advocacy groups, and study participants featured. The benefits of using psychedelics were extolled, with little attention paid to the risks inherent in these treatments being delivered without adequate training. Informal conversations with my peers in recent years often involved a shared concern: The public message seemed to be “psychedelics will fix all suffering with no downside”. We all knew it was more complicated, because we lived it.

Personally, I have been waiting for the proverbial other shoe to drop.  And with the recent FDA decision against approving MDMA for clinical use, we are seeing the inevitable pivot in the press to the cautionary voices and the voices of those harmed, too long left out of the national conversation.

Ketamine, more than the so-called “classic” psychedelics like LSD which are still illegal for clinical use, can be addictive if misused. Almost a year ago, Matthew Perry’s death brought much-needed attention to the risk of unmonitored use. Perry was found unresponsive in a hot tub at his home in Los Angeles, with his cause of death later revealed to be due to multiple sedating substances, pre-existing coronary artery disease, and drowning. One of those sedating substances was illegally obtained ketamine. Though Perry had been receiving legal, supervised ketamine infusions for mental health symptoms in the weeks prior to his tragic passing, the levels in his bloodstream were due to an illegal injection of a massive dose—over ten times the amount used in most medical clinics. In fact, such a high, incapacitating dose is often used for general anesthesia in hospitals.

There is a market for illegal ketamine, and one can’t help but wonder if its touted antidepressant properties have led to more illicit use, as those unable to obtain or afford clinic-based treatment turn to the black market in an attempt to self-medicate their suffering. Science has shown that frequent, high-dose use of ketamine can lead to addiction, resulting in addicts seeking ever-higher doses to feel relief. Doses in these settings are often drastically higher than those used in medically sanctioned treatment, which, importantly, have not been demonstrated to lead to addiction or dependency.  Sadly, Matthew Perry’s escalating doses, obtained through the black market, are not uncommon, a subject the public has not been warned about enough.

In addition to the addiction risk inherent in the unsupervised use of ketamine, there are also risks involved in induced psychedelic states themselves.  Being in an altered state of consciousness is inherently vulnerable. Added to the already vulnerable context of the provider-patient power imbalance, it’s a recipe for disaster when used by unethical or poorly trained providers who may further traumatize their patients,or inadvertently influence them in ways that take away their agency.  This aspect of psychedelic work has led many to raise alarms about harms they are seeing as this emerging type of therapy gains more widespread practice. 

What does this type of work look like though, when done by licensed, highly trained clinicians in safe, medically monitored clinics?

In Robert’s words, when asked to reflect on what he could see about himself on ketamine that he couldn’t see before,

“I don’t want to say the word ‘rewired’, but it has given me a different paradigm, or a different way of thinking, that makes sense. I have had over the years, just feelings of insecurity or feelings of inadequacy…And sometimes I would talk myself into a scenario or think that things were going to be worse than they would end up being. I would make things worse for myself… My own mind was my worst problem. My own self.”

He said of the psychedelic experience, “It feels more real when you’re in it than your everyday reality. It feels like a true or real place. It gives you perspective on maybe you’ve been living a false reality. Or it opens a door, like it is actually okay to feel this way and to think this way…It just gives you that perspective of ‘be open.’ You know, it helped me to be open…”

Outside of sessions, Robert got better at tracking his false self, his “armor”. He began to notice when his armor shell showed up with his wife or kids, or with colleagues at work. He saw how his behavior was controlled, almost automatically, by this shell—this inauthentic, scared version of himself.  He was ready to work on leaving that version of himself behind.

As treatment progressed, Robert’s ability to be present as his authentic, true self increased, and he cautiously practiced letting that new self show up in his relationships and interactions. He appeased less. He ingratiated less. He asked for more. He didn’t let himself be stepped on. What he became was more authentic.

He later told me, “It’s actually helped me to be a better husband and father, and be a better person in my professional dealings with people. But I also call people on their shit, too, if I think that they’re full of it, rather than pussyfooting around… I felt like I turned a page, or closed a book, or opened a new chapter. I just felt like it had saved my life in a way. Because I was having serious self-doubt and feelings of insecurity and thoughts of suicide. And putting too much emphasis on what other people would think of me.… It would put me into a tailspin.”

Polarized views aside, allow me to speak for those of us already doing this type of psychotherapy.  Provided through the already legal, medically monitored use of ketamine by trained doctors and licensed therapists, KAP has great promise as a healing modality.  There is no doubt that patients who have not responded to other treatments for disabling conditions like depression or PTSD often respond to this type of work. And given the extreme suffering those with mental health disorders experience, there has been an enthusiasm, borne of desperation, for seeing this treatment expanded. 

As someone who does this work every day in clinic, I can say that the firsthand witnessing of such patient journeys is moving and compelling.  It was compelling enough to motivate me, seven years ago, to leave my conventional psychiatric practice and commit myself, at some risk, to providing Ketamine-Assisted Psychotherapy, co-founding a training program, the Living Medicine Institute, five years later. I have been doing this work for seven years and have observed our trainees move into the field. Universally, they witness many of their patients healing in ways they couldn’t when only accessing the ordinary-reality state of perception.

That said, my years of boots-on-the-ground clinical work, and those of many of my colleagues, have also revealed a more nuanced reality than the crowing enthusiasm in the media.  For one thing, not everyone responds to psychedelics. The suspected reasons are out of the scope of this article, but it’s worth repeating that for some people, it doesn’t “take”. It’s far from a universal panacea.  Secondly, for the many who do benefit, treatment doesn’t look like the “one-and-done miracle cure” some media coverage would have the public expect. In the real world, Ketamine-Assisted Psychotherapy is, at its core, still a psychotherapy process. It takes work. And time. 

This narrative isn’t as exciting as the “I-took-LSD-one-afternoon-and-it-changed-my-life” story often found in the public sphere. In other words, ketamine, or any other psychedelic substance, is a tool. Used wisely and appropriately, the impacts are massive, but it still requires our existing medical and psychological frameworks to support it. 

Many patients seeking this type of therapy are complex clients who need well-trained therapists and extensive psychotherapy support before, during, and after the ketamine sessions. This is a much more clinically intensive and active intervention than conventional infusion treatments. Though we work with the patient during the psychedelic session, we also use the clinical skills of psychological assessment, treatment planning and goal setting, evidence-based psychotherapy interventions, and understanding how the patient’s developmental history influences the therapeutic relationship and the treatment process.

Thirdly, as mentioned, it is possible to do harm if this work is done badly or by unethical providers. Personally, I attribute much of the documented harms to two causes: poor training on the part of the clinicians, or a fervent over-enthusiasm borne of some providers’ personal backgrounds in underground psychedelic communities. In the enthusiasm to encourage legalization, the cautionary warnings have often been minimized, if not outright neglected.

Biased over-enthusiasm can be countered by education. Inadequate training, however, is a vast and wide problem, because the exponential growth in legal use of ketamine as a psychedelic has outstripped the ability of quality, expert training programs to meet demand. And there is no standardized certification required.  This means that many providers are launching into using ketamine with various forms of psychotherapy, without a regulatory body that vets their qualifications to do so. That body has not yet been invented, and we need it sorely.  Inadequately prepared therapists scattered around the country opening practices is a recipe for disaster, partly because the over-positive media coverage hasn’t prepared consumers to assess for risk. Harmhas been done. The growing advocacy among some to vocalize this harm was part of the climate surrounding the FDA’s decision not to approve MDMA. Only recently have the press and public been told of the potential for these treatments to be dangerous.

So, where does this leave us?  Are psychedelics like ketamine over?

Well, first, it’s too late for that. Another wave of studies seeking FDA approval for psychedelic substances is around the corner, and it’s likely that eventual approval of a previously illegal psychedelic substance is in our near future. Because, ultimately, this new type of treatment works. It’s the job of researchers and the FDA to demonstrate this with actual evidence. It’s also their job to demonstrate clear safety data. And both are likely to happen relatively soon.  Legalization for new psychedelic treatments, in addition to the already-legal use of ketamine, is moving forward.

What’s not moving forward fast enough is regulation of the provider community, the doctors and therapists who will be authorized to deliver these new treatments. Training programs exist, but are not legally required. Those programs can range in quality, anywhere from months-long intensives, to weekend retreats, to a few hours online.  Due to the lack of standardization in the field, there is wide variability in what is taught, leading to a landscape of many clinics opening with minimally trained therapists. Because there is no centralized certifying body, numbers are hard to track. But a quick google search of your local community will reveal ever-increasing numbers of mental health providers offering ketamine-enhanced services.

Let us learn, then, from those of us already in the trenches providing Ketamine-Assisted Psychotherapy.  The many skilled providers who are doing good work, often with previously treatment-resistant patients, tend to be those who have enrolled in thorough, well-thought-out training programs such as ours.  The quality training programs focus on clinical skills for working with psychedelic states, facilitated experiences with different doses of ketamine to understand its subjective effects, experienced teaching staff who have experience in thiswork, and practice opportunities under staff supervision.  They also include safety training—for both medical and psychological safety, ethical approaches to the use of touch, and teaching around particular safety concerns more inherent in psychedelic psychotherapy relationships.

There are some quality training programs, but there aren’t enough to meet demand. And the costs of these more intensive trainings can lead to interested providers seeking out lower cost, less adequate offerings.  We desperately need more quality trainings and certification programs, and we need regulation requiring this, such as a centralized certification body with agreed-upon practice and training standards.

Requiring training through programs like ours that teach both clinical skills and safety in this emerging specialty is the missing piece.  Matthew Perry would not have died if he had been provided ketamine in a clinic under medical supervision.  Unethical therapists who take advantage of their clients, or are too poorly trained to keep them psychologically safe would be less common with standardized training and certification requirements.

Let’s not eliminate Ketamine-Assisted Psychotherapy or “psychedelics” for medical use, because to take away the promise of this type of treatment for those suffering would be more than unethical.  But let’s take the needed steps to make it safer. These should include consensus training standards for training programs and state or federal certification bodies that track providers’ training requirements and allow for reporting of unethical providers.

Interviewed a year after his treatment ended, Robert told me,

…What the ketamine has done is help me realize it’s OK. It’s OK…The world’s not gonna fall apart … It’s helped me to be more accepting and understanding of when the shit hits the fan, it’s not so bad ….It has helped me rewire my brain.

In our current age of polarization in all spheres of life, let’s avoid the tendency to polarize our collective dialogue on this, because extreme for-or-against positions miss the nuanced truth. Let’s instead collaborate on gold standards for a safe treatment environment, so this field can move forward and help more people like Robert live better lives. 

This type of treatment is new.  It’s promising.  The rollout has been messy, and we need more standardization and vetting.  So let’s get working on it.