Ketamine Treatment: D4— Environment, Anxiety, and the Search for Safety

Today is really showing me how much environment may affect my ketamine treatment experience.

I think I need to speak about it with the lead nurse this morning. My daily environment is engorging my anxiety and obfuscating what I was hoping would be the clarity of my treatment.

And that is frustrating.

Because I am here, doing the treatment, trying to be open to whatever happens—and at the same time, I can't exactly separate what is happening inside my head from what is happening around me.

Sometimes the Environment is the Problem

I have to turn down an opportunity that I very much want to take.

It’s a utility role for a production of Richard III.

A utility role, for those non-theatre folks, means that I would be playing multiple characters—which is a pretty juicy opportunity for an actor.

And I want to do it.

But right now, emotionally, domestically, and financially, the pressures not to take this opportunity far outweigh my desire to do it.

One of the things I'm trying to figure out during this ketamine treatment is what belongs to the brain chemistry and what belongs to everything else.

There are things happening inside me that I can't simply reason my way out of. But there are also very real circumstances in my life that affect how safe, anxious, hopeful, or overwhelmed I feel.

And I don't think it's unreasonable to wonder how much those circumstances matter when I'm sitting in a “Zero Gravity” Barcalounger chair trying to change what's happening inside my brain.

Does Your Environment Affect Ketamine Treatment?

I spoke with my  LPN Beth before today’s treatment about the effect of environment on the treatment.

She said she didn't know of research specifically looking at how someone's day-to-day environment outside the treatment session affects the effectiveness of esketamine treatment.

That distinction matters.

There is research looking at the treatment setting itself.

But the evidence doesn't show whether a stressful home environment, financial pressure, or a difficult day will make the medication less effective.

However, while researching, I found some information on pairing ketamine/esketamine therapy with other forms of psychotherapy.

I think that’s important to keep in mind.

According to Psychopharmacology, a 2023 systematic review of ketamine combined with psychotherapy found that the studies were extremely varied in both the psychotherapy used and the way ketamine treatment was administered. They said that the overall results were promising, but the researchers concluded that there wasn't enough consistency to make definitive recommendations about exactly how the two should be combined.

In a 2026 article, “Ketamine-assisted psychotherapies for mental disorders,” in PubMed, a review of 64 articles reporting across 72 studies reached a similar conclusion: ketamine-assisted psychotherapy continues to look promising, but there still aren't enough well-controlled studies to establish whether psychotherapy creates an additional or synergistic benefit beyond ketamine itself.

I had to look up “synergistic benefit.” In this instance they were meaning the pairing of ketamine treatment with psychotherapy. But I could also probably say, “My children are the synergistic benefit of me hooking up with my wife.”

The point is there were only two of the 72 studies that “actively randomized  psychotherapy within the ketamine treatment framework.” So there is not enough clear study to make any pronouncement.

With nearly 17% of adult Americans on antidepressants (according to NIH) I think they probably ought to get a move on the research.

So, when Beth told me that the environment during treatment seems important, I found myself thinking about something much simpler:

Maybe the best thing I can do is control the part of the environment that I actually can control.

And that's good news.

Because there isn't much I can do about everything happening in my life right now.

But I can make choices about what I bring into the treatment room.

The visuals I choose.

The things I listen to.

Whether I work to clear what I can of my mind.

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Treatment 4 Was A Different Kind of Spravato Experience.

Today's treatment was a little different.

Well, not the treatment itself.

The experience of the treatment.

So, I am taking the Spravato treatment, which is the brand name for esketamine. Esketamine is related to ketamine, but it is a specific medication and is administered under a controlled clinical protocol.

This is a nasal spray that I squirt three times into each nostril over a 15-minute period.

The bitter taste sensation is brutal.

Especially if it rolls back into your throat.

At my provider’s suggestion I brought a bag of sour gummies (cherry and peach, thank you) which have actually helped considerably—on multiple levels.

The flavor seems to balance the bitterness and reduce it considerably.

The sensation of having something tactile in my mouth gives me something to focus on. The gritty sugar slowly dissolves, and then the candy becomes this slick, gelatinous little thing that I can manipulate with my tongue.

It gives me a sense of time.

More importantly, it gives me a physical reminder that I am awake.

The physical sensation gives my mind something concrete to grab onto. It helps me stay oriented to the fact that I am conscious and experiencing what is happening.

And that matters.

Finding Safety During Ketamine Treatment

For this session, I plugged into the Limitless app’s microdose option of “I Am Safe.”

This was a great choice for today, since I was not feeling safe heading into treatment.

Not emotionally safe.

Not financially safe.

Not safe in my relationships.

The speaker’s voice for this “meditation” is so soothing and happy that my safety in the session wasn’t ever in question.

I can imagine how some people might not enjoy her voice or presence, but it was exactly what I needed today.

I know there is a growing interest in what happens around ketamine treatment—not just the medication itself, but the psychological context in which someone experiences it.

Research on ketamine-assisted psychotherapy is still developing, and scientists haven't established exactly how much the surrounding therapeutic environment contributes to outcomes.

But my own experience has shown me that feeling safe enough to let go —at least during treatment— is important.

The Visualization that Physically Changes How I Feel

The moment of grounding—creating a visual conduit from the center of your mind to the center of the Earth—had a physical effect on me.

I felt connected.

I could feel the disappointment and moments of sadness move through that conduit like thick liquid through a fabric tube, out of me and down toward the center of the earth to burn up in the magma.

It sounds strange when I write it down.

Maybe it is strange.

But the experience was physical.

I felt lighter.

That's the part of these treatments that is difficult to explain to someone who hasn't experienced them.

There are moments when something that begins as an image or an idea becomes a bodily sensation.

I wasn't simply thinking, “I'm letting go of disappointment.”

I could actually feel something leaving me.

Whether that represents anything clinically meaningful is a question for researchers.

For me, it was meaningful.

And right now, I'm trying to allow those two things to coexist.

Ketamine, Neuroplasticity, and What We Actually Know

There is a reason ketamine and esketamine have generated so much interest in the treatment of depression.

Unlike traditional antidepressants —like Prozac, Zoloft, Cymbalta, or my boy, Venlafaxine (Effexor)— which often take weeks to produce noticeable effects, ketamine can produce relatively rapid antidepressant effects in some people with treatment-resistant depression. Real-world research has found meaningful average improvements, although individual responses vary considerably.

Research on esketamine —which is what I am presently using—is more complicated.

A PRISMA* systematic review and meta-analysis, published in The American Journal of Psychiatry, found a modest overall antidepressant effect from esketamine, while also highlighting significant questions around side effects, long-term outcomes, and the size of the clinical benefit.

Significant questions?

Booooo!

More recent research continues to refine that picture. A 2026 systematic review of ketamine and esketamine in The Journal of Psychiatric Research found evidence of improvement in functional outcomes—including work and psychosocial functioning—but emphasized that depression can affect those areas even when mood symptoms themselves improve.

Yikes!

That last part hits home for me.

Because this isn't happening in a vacuum.

I can sit in a treatment room and experience something profound, bit I have to walk back into a life containing bills, responsibilities, relationships, decisions, work, and opportunities missed.

My brain doesn't stop being my brain when the treatment session ends.

Life is still life.

Therapy after Spravato

I have things to do today.

That’s something they don’t like after a treatment: things to do.

I get it.

Esketamine can cause sedation, dissociation, dizziness, and other effects, which is one reason treatment is administered under medical supervision rather than just tossing it through your car window and sending you home.

Research continues to show dissociation and sedation among the recognized effects associated with esketamine.

But I do have a therapy session scheduled.

This therapist focuses on Internal Family Systems (IFS) and EMDR, and I'm actually curious about what might happen if that session comes relatively soon after the esketamine treatment.

As I noted earlier, the research around combining ketamine with psychotherapy is still unsettled. Reviews have found promising results, but the studies differ so much in their methods, timing, and types of psychotherapy that researchers can't yet tell us exactly what the ideal combination looks like.

I’m not expecting some magical breakthrough.

Though that definitely would not suck.

A Note on My Ketamine Treatment Experience

Look, this is my personal account of treatment with Spravato (esketamine). My experiences—including what I describe as feeling lighter, safer, more grounded, or more emotionally open—shouldn't be taken as evidence that everyone will experience the same effects.

The research on ketamine, esketamine, psychotherapy, and treatment setting continues to evolve.

I'm simply documenting what happens to me because I think the personal experience is worth sharing alongside the science.

Before deciding on doing the esketamine therapy, I looked for personal experiences or reactions to it. And the only thing I really found were these overly positive, seemingly hyped up declarations without any real substance.

I’m just trying to put some personal experiential substance to bubble underneath the research.

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PRISwhat?

I like big terms and I cannot lie.

And sometimes I don’t know exactly what they mean.

I ran across this article that referred to a “PRISMA systematic review and meta-analysis.”

I’ve been throwing the phrase “systematic review” around like nut vendor at a Milwaukee Brewers’ game.

So when I saw it preceded by “PRISMA,” it piqued my interest.

PRISMA stands for Preferred Reporting Items for Systematic reviews and Meta-Analyses).

I guess PRISRMA was just an “R” too far.

Anyhoo, it looks like it’s serious stuff for a researcher.

There is a 27-item checklist that works to make sure that manuscripts contain al the essential elements for a clear manuscript.

There is a 4-Phase flow diagram that writers need to follow to get the stamp of approval.

They are clear that they are not telling anyone how to do the research. They are just creating a clear and uniformed style for reporting that research.

It’s like a Michelin star for researchers.