I didn’t know ketamine could be so psychedelic. I’d done a few lines of it at my house with friends, disassociating from my body as my consciousness drifted on a cloud. But by the time I realized I could have full-blown visions on the stuff, I was strapped into a recliner in a sterile medical clinic—and it was too late to do anything but ride it out. Right there, in the frigid brightly-lit room, eerily reminiscent of where I get my annual pap smears, I turned into an animated cerulean blue blob that melted in the middle of the immaculate white floor. No, I did not see a blue blob. I became the blob.
Ninety minutes or so later, I heard the voice of a male nurse practitioner in the distance, disrupting the ambient soundscape playing through the noise-canceling headphones.
“Shelby?”
No response.
Ten or fifteen minutes later (and what felt like an eternity to me), he came back.
“Shelby?” He said kindly, but a tad more forcefully. “You’re coming down.”
I lifted my sleep mask to be greeted by the gentle eyes of the thirty-something-year-old who, just two hours ago, had given me the rundown for my first ketamine infusion.
“How was it?” he asked.
“Honestly,” I said, “I didn’t know ketamine could be that strong. I’m really glad I have experience on ayahuasca and know how to navigate psychedelic states,” I told him as he knowingly chuckled.
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Shortly after, still feeling like I had had one too many beers and was walking with the legs of Gumby, I was sent on my way: out the front door of the clinic, into the hallways of the dreary medical building, down the elevator, and onto the curb where, still tripping, I waited on a bench on a dark December night for a friend who was on the way.
Over the next two weeks, I did six ketamine infusions at the clinic—a fairly standard treatment plan for a first-timer—to treat low-level depression and anxiety that had created a heaviness in my body for as long as I could remember, getting more severe in recent months. The infusions cost me about $3,000 and were not covered by insurance—something that is also standard and part of why it took me so long to give them a try.
As is typical with more traditional psychedelics such as LSD and shrooms, every journey was different—and varying degrees of profound. In one of my first infusions, I had a vision that I gave birth to myself. Later in the series of treatments, as though the narrative was being picked up where it left off, I reflected deeply on what I understood to be involved in motherhood, from giving birth to watching that child go out into the world. I saw the whole process in 8mm film, projected onto a wall within my mind, as though I’d already raised my child, and was just watching it back.
In the past, my answer to people when they asked if I “wanted kids” had always been yes, but a part of me had doubted whether that was true. I left that experience sure that I’d like to give birth to one child (just one), and nine months later, that surety remains. But my depression and anxiety didn’t shift in meaningful and sustainable ways—at least not according to how I felt, the observations of my therapist, or the surveys I took at the clinic before each infusion in an attempt to measure my progress. Needless to say, after taking money out of an account I never touch, left to me by my grandmother for a downpayment on a first house someday, I was disappointed—and also, as a journalist who has devoted her life to writing about psychedelics—felt an obligation to share my experience.
Amidst the growing interest in psychedelics for mental health, but their continued prohibition in most parts of the world, ketamine clinics are proliferating as a legal alternative. There are now an estimated 500 to 750 ketamine clinics in the U.S. The industry has seen rapid growth, with market revenue estimated at $3.1 billion in 2022 and projected to reach more than double by 2030, according to a market analysis by Grand View Research. Most of these clinics administer ketamine intramuscularly (basically a shot) or intravenously (as an IV drip), although some also administer it rectally, and as lozenges, which can be taken at the clinic or prescribed for at-home use. Additionally, in March 2019, the FDA approved a ketamine nasal spray, called Spravato, for depression, which is administered in the clinic. The upside is that, because it’s been approved for depression, in some cases, it’s covered by insurance.
New laws and relaxed or expanded regulations passed during COVID also allowed for a blossoming ketamine telehealth industry, whereby patients around the U.S. and Canada can, after an often brief psychiatric evaluation, order ketamine lozenges to their homes via mail. There’s been controversy around this treatment model because some practitioners express concern over the lack of oversight. Patients are supposed to, for example, have a trusted friend keep them company during the experience, but there’s no confirmation that they do—and some of the dosages prescribed are high enough to cause complete disassociation (colloquially referred to as a “k-hole”).
“There are many thoughtful, good-hearted, diligent doctors in this country who are trying to offer quality care and they are becoming grouped in with low supervision telehealth companies that have simplified the process so much, and made access so easy, that the FDA and DEA are starting to look at the entire ketamine industry as a problem,” says Dr. Jeffrey Becker, a psychiatrist and expert in the field of ketamine-assisted therapy.
One of the biggest challenges in the ketamine industry is that most of the ketamine being administered now for mental health—everything but the Spravato nasal spray—was never actually approved by the FDA as a therapeutic treatment. Ketamine was approved in 1970 as an anesthetic for surgery. It’s administered for therapy under what’s called an “off-label” prescription. This basically means it was approved for one condition, but doctors are prescribing it for another—and this is why it’s not covered by many insurance companies and infusions typically run in the thousands of dollars. It’s shown incredible promise, particularly for patients with acute suicidality, but also has the potential for abuse and can cause bladder and kidney damage if taken too frequently.
Anecdotally, I’ve heard stories (and seen people) snort lines of ketamine and pass around homemade ketamine nasal sprays on the dance floor like it’s cocaine. The drug is all over Burning Man, Lighting in a Bottle, and every other festival and rave that attracts the LED-wearing, EDM-bumping crowd. And I can tell you that even as I was doing those six infusions over a period of two weeks—and later lozenges at a cadence of two to three sessions per week—I started to really like the stuff and have cravings. Nothing unmanageable, but my longing for it had a subtle fiendish quality, in stark contrast to more classic psychedelics that beckon me back slowly and with more intention.
Alongside debate over the varying administration methods, there’s also ethical rifts over the level of professional support that should be provided during the experience. Dr. Erica Zelfand, a licensed family doctor specializing in integrative mental health and functional medicine, understands the value of providing support and the challenges in doing so. In response to criticism around the at-home ketamine model, she tells me, “For some people, it works great. For other people, it’s a disaster,” noting that ketamine, as a drug, is so marketable because it’s “pretty darn safe.” “It’s been in use above board since the 1970s,” she says. “So we’ve got a good grip on its contraindications and side effects.”
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Even still, Zelfand, who has a private practice where she administers ketamine and trains other practitioners, says she feels it’s important for her to assess the needs of each patient and develop a treatment plan specifically for them. Becker, who also serves as a Board Member for the American Society of Ketamine Physicians, Psychotherapists, and Practitioners (ASKP), says he feels one-on-one support is vital, and that, in comparison to simple medication management, he loses money on his ketamine treatments, because of the level of care he feels obligated to provide each patient.
“I don’t think anyone should have their first four or even six treatments alone, ever,” he says. “And I’ve been in the field for a long time. I’ve been approached I can’t even tell you how many times by different companies saying ‘let’s scale what you do,’ and I’ve explained repeatedly that it’s impossible to scale what I do without reducing the quality of care and follow-up.”
Before I got my first round of infusions, I was aware of this debate around the varying levels of care provided to patients—it’s why I chose a clinic that’s considered one of the most reputable. They did a thorough intake of my medical history and the process from check-in to infusion felt like a concierge doctor, replete with meditative music and a pastel-colored waiting room.
The day of my first infusion I wasn’t given much information on what to expect. I, frankly, expected it to be pretty mild for someone who has done LSD and shrooms several dozen times. The nurse practitioner, in scrubs and with a mask on, took me into the room and, like at any other doctor’s, confirmed all the information on the forms I’d filled out.
“Any other questions?”
“Um, not really.”
He placed a strap around one arm, which continually inflated and squeezed my bicep to check my blood pressure; inserted the IV; covered me in fuzzy blankets; surrounded me in pillows; placed the noise-canceling headphones over my ears; and pulled an eye mask down onto my face. I was told not to move too much so as to dislocate the IV. He then placed a call button on a lanyard around my neck and positioned a camera in front of me where, from a room a few doors down, the staff would monitor me, alongside several other patients, remotely. It all felt dystopian—being watched while I tripped on a camera a couple feet from my face—but I tried not to let that narrative seep in too deeply, reminding myself that some people might feel comforted by all the precautionary measures. I was in complete darkness and silence when the nurse practitioner lifted the headphones so I could hear him.
“I’m about to start the IV now, are you okay?”
“Yes.”
“Okay, we’re starting now. Just push your call button if you need anything.”
Within a few minutes, I started to feel a floating sensation, and the darkness transformed into a galaxy of stars, something that’s not uncommon among people who do ketamine. The “keta-verse” is often described as having a 1980s video game feel, like Pac-Man meets Star Trek. As I started to disassociate from my body, I reached for my call button, wanting a hand to bring me back down to earth for a moment. Weighed down by what felt like five pounds of blankets and self-conscious about bumping all the medical equipment beeping and inflating and pumping around me, I carefully searched under what felt like layers and layers of soft material and pillows. Frustrated, I gave up and tried to relax. But then, the thought creeped back in again: I want to talk to someone to feel comfortable releasing into this experience, I just want to talk to someone. Remembering that they were monitoring me via a camera, I tried a new tactic.
“Human? Hello? Anyone there?”
Nothing.
It felt like an eternity before someone was by my side.
After that experience, I expressed to them that I would feel more comfortable if someone stayed in the room with me, at least as I blasted off. They responded with understanding and, during my next infusion, a nurse practitioner who, in a state of disassociation, turned into a loving mother panda, stayed by my side. “Mama bear,” I kept saying as she squeezed my hand.
“Are you okay, Shelby?” she asked.
“Yes, I’m ready to float now.”
“Okay, float,” she said sweetly, as I took a sigh of relief and her hand slipped out from under the blankets.
This nurse practitioner became my angel throughout my infusions, when she happened to be on staff. But she wasn’t always there, and once I ended up with a seemingly, well-meaning, but aloof nurse practitioner who reluctantly held my hand, making me feel more uncomfortable than if I had toughed it out alone. The point is: Sometimes I was supported, and sometimes I wasn’t. But none of the people there were trained to support me and the ones who did seemed to be doing so out of kindness. There was no consistency in the faces that I saw, and I never knew who would be administering the IV that day.
“What you’re getting at and what you’re experiencing in terms of best practice is a big problem right now,” says Becker, after I share my experience with him. “Really, what’s happening is people aren’t being clear about what their parameters are. Is it what’s most effective? Is it what’s safest? Is it what provides the most access? Those are all very different values that are being put forth by the parties involved.”
Becker says he thinks, based on general opinion, that the most effective treatment model is administration via IM or IV in a clinic with a therapist who is trained. But he also understands the real-world challenges of that, both for businesses and patients. For businesses, it’s expensive to provide that level of support. And for patients, it’s expensive to receive that level of support—and also can be logistically challenging, as clinics can be far from where a person lives, and you’re not supposed to drive yourself. In order to do my treatments, my best friend created a spreadsheet whereby my friends, bless their hearts, took turns sitting in rush hour across Los Angeles to pick me up and drop me off. I had to take two weeks off work, because each excursion was about four hours, door to door, and the clinic was only open Monday through Friday during work hours.
That’s why, six months after my infusions, despite the reluctance of some of my previous sources, I decided to try the at-home model. That, and the fact that I felt, as a journalist covering psychedelics, that it was my responsibility to give this other modality a try.
For most of the ketamine telehealth companies, it seems the standard protocol is to fill out an inquiry form on their website and then, if you’re a candidate, to be invited to sign up for a call with a licensed clinician. My evaluation was brief. They asked me about my mental health and medical histories as well as whether I was on any drugs that might be contraindicated with ketamine, but they didn’t ask for records. I basically told them I had met with a psychiatrist who had diagnosed me with major depressive disorder—it was true, but they didn’t verify. They then approved me and we discussed how many sessions I wanted to do, four or eight. They prescribed me enough lozenges for eight sessions—each was 300 mg and they recommended that, after a trial session where I take one to familiarize myself with the feeling, that I up my dosage to two per session, or 600 mg.
After those sessions, I ordered another sixteen lozenges for eight sessions, which cost me $396. After a brief consultation before renewing my prescription, they upped my dosage to 800 mg per session. It was only afterward, when I began this reporting, that I was told by independent sources that that’s an extremely high dose. Becker tells me that in some people, swallowing 800 mg could be fatal. Luckily, I followed the instructions and didn’t swallow, but spit them out.
Nevertheless, the first eight sessions were transformative—and I was much happier in my own bedroom, with my twinkle lights and my favorite music and the ability to roll around or get up and stretch as I pleased. When the experiences were over, there was no need to wait for a friend to drive me across town. I could journey on a Saturday, when I was already off work, and then take my pup for a walk around the neighborhood when I felt stable enough. Most of these sessions ended with a feeling of the “afterglow effect,” an ephemeral, pleasant state of being that can follow the days, weeks, and months after a psychedelic trip.
When I think back on the potential of the lozenges, I recall a journey I did at a friend’s house near the end of summer in the Los Angeles neighborhood of Larchmont Village. She lives in a breezy, white apartment with high ceilings and French windows that open to a street lined with trees and craftsman homes. When the medicine faded and I was able to stand up, I leaned out the window, the breeze hitting my face and took a sigh of relief. Is this what it feels like to not have depression? I thought. Is this how ‘normal people’ feel all of the time?
When I had come down fully, I drove home in my convertible, top down, wind blowing through my hair. Instead of taking the freeways with back-to-back traffic to save two minutes (literally), I set my GPS to “no highways” mode and cruised down Western Avenue through Koreatown, coincidentally passing a “cheap eat” that had been on my bucket list for a while. I swooped into the parking lot for, what turned out to be, the world’s most delectable rotisserie chicken.
But the feeling soon faded. Within a week or so, my depression and anxiety started to seep back in like a black cloud on the horizon, foreboding rain—and what was left were the “revelations,” those shifts in perspective from the trip that I hoped to integrate into my life. At the time, I thought back to the licensed clinician from the telehealth company who had definitively told me “the psychedelic effects are just a side effect,” in the same breath that she breezed past me mentioning that I thought I needed more sessions because, within a month, my boyfriend broke up with me, my grandfather died, and my car was stolen. Good thing I’m not relying on these people for therapy, I thought.
As it turns out, whether the psychedelic effects of ketamine are “just a side effect” isn’t that definitive. “I personally believe that with skilled support and a willing psyche that there is a lot to be gathered from the symbolism and encounter with self during the ketamine experience and we know based on functional imaging, based on EEG studies, looking at what happens when ketamine is in the brain of someone who is depressed or not depressed, that there is a huge increase in brain interconnectivity, between areas of the brain that are normally not able to talk with each other,” says Becker. He believes the symbolism often experienced on a ketamine journey can be interpreted through a “Jungian” (as in the Swiss psychiatrist Carl Jung) lens, and that “the content is hard to understand for patients, honestly, for a lot of doctors and therapists, even, to understand.”
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Zelfand says, in her mind, ketamine and therapy are like “peanut butter and chocolate.” They go really well together, but they don’t necessarily have to go together for the ketamine to be effective. “I’ve had patients where the ketamine experience is like a mini-ayahuasca journey,” she says. “And then sometimes I have patients, they’ll have just a very confusing, dysphoric, kind of psychedelic manic garbage soup experience and they get very discouraged and what I say to them is, ‘you can still heal without having a particularly meaningful trip; part of how it works is the biochemical activity.’”
Whether therapy after ketamine is necessary, or even helpful, is another point of controversy within the field. In the context of tripping on more traditional psychedelics such as shrooms, LSD, and ayahuasca—as well as MDMA—it’s widely accepted among researchers and therapists that integration is integral to maximizing the benefits of the experience. The idea is that the benefit not only comes from the neurological changes catalyzed by the substance, but also the shifts in perspective—and that recalling and processing those in therapy can sustain those shifts over time.
In my experience, already having an integration therapist who I work with regularly has been extremely helpful as I’ve come back to the thoughts I had both during my infusions and on the lozenges. Nine months after my infusion, where I had a vision of myself being pregnant, I’m still sure—in a way that I never was before—that I want children. And every day, I repeat a thought I had to myself during one of my lozenge sessions as though it’s a mantra: “I don’t have to do anything right now.” This, to me, doesn’t mean all my commitments dissipate, it’s just a reminder of what I realized during that session: that I often overcompensate for feeling like who I am, inherently, isn’t enough—and that my worth is determined by what I do, what I accomplish. I say the mantra, and my muscles unclench.
Has my depression gone away? No. In fact, I don’t think any of these journeys led to meaningful changes in the clinical surveys that try to quantify a person’s mental health. But they feel meaningful to me. I say this with a big caveat being that I also experienced moments both in the clinic and at home where I felt these treatments were, frankly, negligent. I was deeply grateful to be a person who, I feel, has a decent amount of psychedelic navigation skills so I could hold myself through some destabilizing experiences that I had not been prepared for. Does this mean that either of these companies, or that the impact of the ketamine industry, more broadly, is net negative? My statistically insignificant sample size of friends wouldn’t lead me to believe so. I’ve heard far more stories of transformation—of people having their lives “saved” (in their words) when they were acutely suicidal—by ketamine, bought on the black market and done underground, taken as legal lozenges at home, and received in a clinic. But the challenges the industry faces do speak to this moment in psychedelic history whereby the economic realities of providing access to medicines that have not yet been approved by the FDA for mental health are colliding with a growing need for novel treatments.
“When you pencil out what it takes to make money, you have to reduce the quality of the care and the one-to-one contact that takes place with highly skilled individuals,” says Becker. “This is what’s happened. It’s a simple economic issue that I think has done some real damage to the field, and, yet, I understand why it’s happened. It’s complicated.”
*This essay was originally published in DoubleBlind Magazine Issue No. 12. You can purchase it here.
