March 1, 2024

A case for Ketamine and manualized psychotherapy

Owain Winfield

Psychedelic therapy heralds a new era in healthcare, particularly in Western contexts, despite its longstanding use as a therapeutic tool in indigenous cultures worldwide. The mass adoption of psychedelic therapy in Western medicine necessitates a change in many mindsets; it requires not just a public shift in the perception of altered states and the compounds that induce them, but also a departure from many of the established conventions surrounding how mental health conditions and addictions are addressed. This shift may seem overwhelmingly huge, even impossible, but perhaps less so for some compounds when combined with some psychotherapeutic practices. By looking backward and examining the path taken by other treatment approaches to gain public trust and acceptance, valuable lessons can be learned.

Change:

We live in an era of evidence-based practice, and rightly so. While psychedelic approaches are not new, the development of an evidence base to facilitate trust and adoption into Western medicine has been hindered by legislation and heavy hand drug laws issued by Western governments. However,momentum is building, and we are now well into a period of significant scientific investigation with the potential to usher in substantial changes in day-to-day clinical practice. This presents distinct challenges, including the need to shift public perception, train and upskill healthcare workers and therapists, and adapt existing mental healthcare infrastructure to prevent overwhelm. Cognitive Behavioural Therapy (CBT) has traversed a similar path. Just twenty years ago, the majority of people in the UK would not have considered psychotherapy, let alone accessing mental health treatment due to associated stigma. However, despite these odds, CBT has achieved remarkable success. In 2008, the UK rolled out the national Improving Access to Psychological Therapies (IAPT) program, which now receives approximately 2 million referrals annually, with the average completed treatment episode receiving 7-8 sessions of CBT. The story of CBT’s rise not only underscores the potential for change in attitudes and practices, but it also offers lessons and a model by which psychedelic psychotherapy might reshape mental health and addiction treatment paradigms. 

The Promise of KAP:

Among psychedelic compounds, ketamine stands out as a bridge to bring psychedelics to the general public. Its legal status and off-label prescribing opportunities differentiate it from other psychedelic therapies, making it a practical and viable option. Ketamine has not only been widely and safely used in medicine for many decades, but its been used at much higher doses in anaesthesia than those required to induce a psychedelic experience, making the move to its broader use with therapy a smaller step that that required for a compound like psilocybin. Compared to classic psychedelics like LSD or psilocybin, ketamine allows for shorter dosing sessions, enhancing its accessibility and feasibility for patients and healthcare providers alike. Ketamine-Assisted Psychotherapy (KAP) is rapidly gaining evidence, showing increasing promise in providing significant relief for individuals grappling with treatment-resistant psychiatric disorders and addictions, such as alcohol use disorder, depression, and PTSD, through the synergistic effects of ketamine and psychotherapy.

The Need for Standardization:

Despite its promise, the integration of KAP faces a significant hurdle: standardisation. The proliferation of ketamine-based research presents huge variation in KAP treatment protocols, particularly regarding the psychotherapy components of treatment. The emergence of numerous ketamine clinics, particularly across North America, has exposed inconsistencies in KAP delivery, posing potential risks to patient safety, therapeutic outcomes, and the public perception of psychedelic-assisted psychotherapy as a whole. Without standardised evidence-based KAP protocols, KAP will remain fragmented and unpredictable in the eyes of policy makers, commissioners, clinicians and the public.

Applying CBT's Success to KAP:

In 2006, Lord Layard produced The Depression Report: A New Deal for Depression and Anxiety Disorders in the UK. The report examined the impact of depression on the economy and proposed the implementation of a psychological treatment program known as the national “Improving Access to Psychological Therapies” (IAPT) program, based on CBT. CBT was chosen not only for its effectiveness but also because it had attracted considerable research attention and developed substantial evidence-based standardised treatment protocols. This allowed for the economic case to be presented to high-level commissioners in a language they understood. Over subsequent years, the therapy infrastructure in the UK has developed significantly, with IAPT services transitioning from small teams delivering therapy in borrowed spaces to dedicated NHS therapy clinics, large teams of hundreds of therapists, well-established postgraduate training programs, and mature outcome monitoring and governance structures. All of this has been achievable because of the standardisation of treatment protocols, offering measurable units of CBT that can be evidenced, trained, outcome monitored, and clinically governed.

Psychedelic psychotherapy needs to follow this path. While the dream of a complete and rapid overhaul of mental health services is held by many, the reality is likely to be more incremental and slow, similar to the trajectory seen with psychotherapy and IAPT over the past decade. Psychedelics will need to meet the establishment halfway, and mass adoption of these approaches will involve collaborative efforts to develop standardised evidence-based protocols, manualization of disorder-specific treatment guidelines, standardised training for therapists, advocacy for policy and insurance coverage, and continuous evaluation and adaptation. These measures, combined with the accessibility of ketamine, are likely to be our route to “Improving Access to Psychedelic Psychotherapy.”

The journey toward incorporating psychedelic therapies into conventional healthcare systems marks a pivotal evolution in treating mental health disorders. Drawing from the experiences and methodologies that facilitated Cognitive Behavioural Therapy's (CBT) acceptance and integration, we recognise the significance of standardisation, evidence-based practices, and collaborative efforts in overcoming the challenges of public perception and systemic integration. The path forward necessitates a concerted push for the development of standardised protocols, training programs tailored for therapists, and strategies for policy and insurance advocacy, underpinned by rigorous evaluation and adaptation processes. These efforts and leveraging ketamine's unique position due to its accessibility and proven effectiveness, we edge closer to a future where access to these treatments is not just an aspiration but a reality for the broader public. The collective endeavour now is to strategically and cohesively present our evidence and treatments in a manner that aligns with healthcare commissioning standards, ensuring the realisation of this innovative approach to mental wellness.

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