Is the COVID pandemic presenting us with a new opportunity in the field of psychedelic-assisted psychotherapy? Can we collaborate with patients to offer virtual sessions safely and effectively? If so, what are the implications of this new way of providing treatment? Join Dr. Eric Sienknecht, PsyD and Veronika Gold, LMFT in an exploration of offering ketamine-assisted psychotherapy during social distancing.
In mid-March 2020, as the Shelter-In-Place order was put into effect in San Francisco, nearly all businesses and services ground to a halt. We stayed home, canceled all plans and appointments, foraged for the meager supplies remaining in stores, and waited. Our ketamine-assisted psychotherapy clinic, Polaris Insight Center, was closed for business, indefinitely. As fears of infection spread, along with the virus, we worried about our many patients, some of whom were suffering from Treatment-Resistant Depression and Anxiety while others reported newly emergent symptoms, exacerbated by the stress of the pandemic.
The question on hand became: How could we best respond to this potential healthcare crisis?
After several meetings, and as Telemedicine and HIPAA regulations were relaxed, we decided to begin offering virtual ketamine-assisted psychotherapy (KAP) sessions. Although our physicians regularly provide suitable patients with prescriptions for ketamine lozenges for at-home use during maintenance phases of treatments, we typically require in-office medical and psychological evaluations and several in-office KAP sessions before transitioning to at-home regimens. In this new COVID era, we would now be conducting evaluations, determining treatment plans, and facilitating the self-administration of ketamine lozenges at home via Zoom, all without ever meeting the patient in person.
Readers with an understanding of the powerful, often transformative, effects of psychedelic medicine may be skeptical and may wonder, “How is this possible?” and “Is this safe?” We also had similar questions, which informed the development of a new protocol for virtual services that included additional requirements to maximize safety and support.
Consider these three dimensions of virtual ketamine-assisted psychotherapy:
Virtual KAP is more affordable compared to in-office treatment: Standard KAP treatment is a significant time investment. Typical treatments will include, at minimum, 1/2 hour with the physician, 1-hour intake with the therapist, 1 – 3 hours of preparation, several 2- to 3-hour experiential sessions, and 1 or more 1-hour integration therapy sessions. Because off-label use of ketamine is not usually reimbursed by insurance companies, the 10 – 20 hours or more of treatment are typically paid out of pocket. Virtual sessions allow for savings on rent in clinics and allow clinicians to see more patients, as there is less time spent between sessions (in the waiting room, in transition between session and transportation, changing sheets, and resetting the room).
Virtual KAP is more accessible compared to coming in person to the clinic: People who live in remote areas and places where there are no Ketamine-Assisted Psychotherapy clinics can now have access to this treatment.
KAP is most often used to target Treatment-Resistant Depression. One of the common challenges with depression for people is finding the motivation to engage in treatment, i.e. planning for sessions, leaving the house, and driving to and from appointments. With virtual sessions, these roadblocks are removed, facilitating access to, engagement in, and delivery of treatment.
The home setting can be more convenient for supporting the inner process and reducing side effects: Patients can stay with their process without interruption beyond the time of the session. Ketamine can elicit non-ordinary states of consciousness and, even when patients return to their normal state of consciousness, the physical effects of the medicine can continue beyond the time of the session. For this reason, many clinics, like ours, have “recovery areas” where patients wait, and patients are required to have arranged a ride home. When treatment is done at home, the patient can stay in their bed or on their sofa for as long as they need, and there is no pressing need to shift the state and commute home. One of the most common side effects of ketamine therapy is nausea, which is exacerbated by movement, and so this is greatly decreased during at home sessions where the patient can stay in a comfortable position as long as they need.
Due to limitations of the online format, there is a greater need to communicate instructions clearly. During in-office sessions, the therapist/physician team are responsible for creating the setting and co-creating the set of the sessions. During online sessions, the patient has to prepare the set and setting themselves. As such, additional communication around details of preparation – from interacting with the compounding pharmacy, to learning how to use the lozenges, to setting up the music, to navigating online platforms – are needed. Instructions need to be explicitly spelled out and often repeated. In short, more energy and effort are required by the provider on the front end to facilitate a smooth, safe, and supportive experience.
Virtual sessions in the familiarity of the home environment are experienced as safer for some patients, allowing for the possibility of greater vulnerability and increased capacity to fully let go into the therapeutic process. As human beings, we are wired for relationships and in healthy individuals, personal contact and connection facilitates relaxation, feelings of joy, and openness. However, for many people who suffer with depression, anxiety, and PTSD, personal contact and/or being in clinical settings can increase their discomfort, thereby creating an obstacle to depth exploration.
Safety concerns for our patients and legal concerns for our clinic required us to spend more time and energy upfront anticipating risks and creating contingency plans. We developed new informed consents, including a telehealth consent and an at-home lozenge-use consent, describing in detail set and setting requirements, safety plans, and the importance of support systems. Additionally, since we would be expanding our services to people outside the Bay Area, we created new contact lists for local emergency services for various areas in California.
3. Support System
Particularly since the pandemic, there has been a greater need for connection with others and as well with those who are familiar with KAP. . We have found ourselves sharing more community online resources with our patients and discussing the importance of Ketamine Integration groups. We have seen much more interest in virtual support groups such as the weekly Psychedelic Integration Circles with Tam Integration and Polaris Insight Center and the weekly Ketamine Integration Circles with Sage Integrative Health.
The patient’s support system is even more important if they are engaging in virtual sessions. Time and energy are needed to communicate with the patient’s support system. In cases involving extreme social isolation, inability to communicate with others and/or absence of a support system could be a major obstacle to this kind of treatment.
Compared to in-person sessions where the therapist/physician is physically present and can provide verbal and physical support, patients can sometimes find it harder to take in the support in a virtual session. As such, having a sitter present during the session, in the same or separate room, or at least someone who is aware that the patient is taking a journey and who can be on-call if needed, should be arranged.
The favorable outcomes we have witnessed thus far with this new method of collaboration between providers and patients have broader implications for our healthcare system. Patients treated at home might be less dependent on the system for their healthcare needs, resulting in greater self-empowerment and agency, and less strain on the healthcare system. Furthermore, with at-home sessions being significantly less expensive than in-office treatments, access to care would widen.
As at-home sessions are being provided by more clinics, it will be important to track safety and efficacy in an ongoing way, and protocols will need to be revised accordingly. Nevertheless, after successfully facilitating many at-home treatments, it is our belief that virtual KAP sessions can be provided safely and effectively when paired with sufficient screening, preparation, and support.