Implementing the Ketamine-Assisted Psychotherapy Approach

Michael J Verbora, MD, MBA, medical director, Field Trip Health, asks Ben Medrano, MD, medical director, Field Trip Health, Toronto, Canada, to explain ketamine-assisted psychotherapy [KAP] implementation and the experiences patients have had with the treatment. 

Dr Medrano is also the chief medical officer at Aleafie Health, and assistant professor at Seneca College, Ontario, Canada.

This discussion took place at the 2021 Psych Congress in San Antonio, Texas.

Read the transcript:

Dr Michael Verbora: Can you walk us through the model of ketamine-assisted psychotherapy and what that looks like? 

Dr Ben Medrano: Happy to. Well, there's a few different models on how to do this in the field. I want to point that out because what we do at Field Trip Health is not so unique, but we do have our own approach. 

A lot of what we see being done with ketamine-assisted psychotherapy is a bit of hybridization of the research that you're seeing right now on [3,4-Methyl​enedioxy​methamphetamine] MDMA and psilocybin. When I say hybridization, what I mean is that we're taking the structure and format of the therapy delivery of the actual talk therapy portion of what's being done, and say the MAPS [post-traumatic stress disorder] PTSD Phase 3 trials. 

What we do is we deliver the medicine at specifically time points and we sandwich that with the psychedelic therapy's prep and integration. We're trying to allow people to get ready for what the experience is so that there are no surprises. 

Also, beginning to put a frame of thought around their goals of what the treatment is for, to put it into context as to where they came from in their life. Even just going back to my own personal story to reflect on those painful memories that I was working with, and bring that into the context of the therapy. 

At Field Trip, we deliver ketamine either sublingually up north of the border in Canada, but also intramuscularly down in the United States. Our hope is that by delivering it in that way, one can have a trajectory of their experience that is likened to other psychedelic journeys. 

Intramuscular, in particular, allows a rise, peak, and decrease of the subjective experience that is likened to a psilocybin journey, I think, for some. It has its own unique flavor, of course, different visuals, different kinds of synesthesia. It's not totally the same. 

After receiving the medicine, you meet with your therapist, and this may be a day or 2 later, and you begin to integrate the experience. What are the things that arose in the experience that may have felt abstract, or difficult memories, or physical feelings, those kinds of things? You just begin to unpack them. 

That is the integration I say is where the real work happens, I would say. A lot of people get focused on the medicine, but for us at Field Trip, at least talking to the other therapists, we find that that's where people make some real breakthroughs. 

We repeat that cycle of dose delivery and integration a few times over. We try to follow the literature with IV ketamine, which is 4 to 6 doses over a condensed period of time, like 2 to 3 weeks, and then we couple that with the therapy in between. 

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Dr Verbora: Can you share a little bit about what are some of the experiences that patients have when they undergo this process or journey through KAP at Field Trip? 

Dr Medrano: I'll share a little bit also within the frame of my own experience because it's potentially more convincing for people when you hear it from somebody who's actually tried it. 

I would say -- and this is the theme of what I've seen other people go through -- the first part is getting familiar with the medicine. What is it like, what does it do to one's consciousness, and how does it affect their relationship even just with the therapist, let alone the world around them? 

There's this early part of familiarization of saying, "Now I know that the medicine may make me feel a little weird." It's really for lack of a better term. That's the most common way I hear people describe ketamine. "That was weird." 

My experience personally has been one where I feel a sense of being able to step out of the thought loop or the rumination of the history of the pain. Even if you have, say, a particularly negative self-view as we see a lot in depression, to be able to step out of that narrative and look at it from different angles. That is a theme I hear with most of the clients. 

It is a true indicator of the name of ketamine as being dissociative. Instead of dissociative in the sense of a negative symptom of trauma, it's dissociative in a positive way because it gives people some agency to begin to take a different perspective about themselves, their illness, the painful past, whatever that might be. 

That is probably the hallmark of the work, at least for me and for what I've seen with other people doing this therapy. There are other approaches, I would say, towards healing. I would say that there's no one journey or trip is the same. 

I've heard other people feel that they've processed pain somatically. Some people will describe energy moving through their body. I've had clients moving around a great deal in the treatment chair. 

Other people will find themselves having essentially abreaction, like reliving of a trauma, but there will be a sense of safe distance from it, so that they can begin to move forward with that, with whatever stuck pain that they might have from that. You'll see a lot of cathartic release, crying, and yelling. 

The other thing that comes to mind about ketamine is the fact that we have decided to start calling it a psychedelic. For classically-trained psychiatrists and physicians, we think of psychedelics as 5-HT2A agonists, and ketamine is clearly not that. It's an MMDA antagonist. It's pretty far from what we would normally think of as a classic psychedelic. 

When I think of the mechanism of psychedelics, I think of mystical experience, in particular, and we even have our own questionnaires to measure that. When we look at ketamine, we see consistently mystical experiences at the higher doses. 

Why is that important from a therapeutic point of view? Having a profound experience, a noetic experience, these are the insights that provide us with a deeper felt meaning rather than a conceptual one. When people have that, they find that they can move forward sometimes.