Ketamine-assisted therapy within a community of practice: a novel approach to disordered eating

Introduction

“Disordered eating” refers to chaotic or abnormal eating patterns, including conditions such as anorexia nervosa, bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder, and emotional eating. ¹ Disordered eating patterns involve maladaptive relationships with food, body image, and self-perception, intertwined with mental health issues.^{2 –4} Addressing the cognitive distortions behind disordered eating, such as emotional regulation difficulties and avoidance, is crucial in promoting intuitive eating—a more adaptive and healthy approach to food.^{2 –5} Furthermore, creating a sense of safety and groundedness enables individuals to develop resilience, which plays a key role in overcoming eating disorders.^6,7

Given the high prevalence of eating disorders, affecting approximately 1 million Canadians, and their associated mortality rates—the highest among mental illnesses (with estimates of 10%–15% mortality), innovative approaches to treatment are crucial. ¹ Traditional therapies for disordered eating, particularly those addressing food restriction, such as group cognitive behavioral therapy (CBT), are common; however, there is growing interest in alternative modalities such as psychedelic-assisted therapy (PaT).^{8 –12} PaT, and more specifically, ketamine-assisted therapy (KaT), is increasingly being studied for its potential to treat various mental health conditions.^2,11,13 Robison et al. ¹¹ reported findings in a case series where patients experienced symptom reductions across both their eating disorders and comorbid mental health conditions following group-based KaT. Ragnhildstveit et al. ¹⁴ demonstrated that repeated ketamine infusions resulted in complete remission in a patient with BN, sustained at a one-year follow-up. This highlights the need for further exploration into combining these two therapeutic modalities.^5,11,15

Currently, there is a lack of research examining the synergistic effects of specifically combining KaT and group therapy for disordered eating, despite KaT showing promise in treating a range of mental health challenges.^13,14 Moreover, literature demonstrating the potential of psychedelics in a multimodal, team-based approach to building resilience and cognitive flexibility is limited.^{2,11,16 –18}

Addressing trauma and comorbidity in eating disorders

Eating disorders are often associated with a history of trauma, abuse, and neglect, alongside comorbid conditions such as depression and anxiety.^2,5,19 PaT offers a unique opportunity to address these underlying traumas while improving resilience and cognitive flexibility. Cognitive shifts from top-down, rigid thinking to bottom-up processing can lead to more adaptive responses to emotional discomfort, reducing the need for disordered eating behaviors.^2,11,20

Research indicates that PaT can enhance resilience by increasing tolerance for difficult emotions, facilitating a shift from avoidance to acceptance and empowerment.^3,11,16 By addressing both the psychological and physiological aspects of eating disorders, PaT can help individuals develop a more balanced approach to food and self-care.^2,4

Potential adverse effects of KaT

Investigations into KaT have yielded ample safety data, and a recent review on the long-term effects of ketamine found that they are typically self-limited, mild, and transient.^{21 –26} Common and expected effects of ketamine include: a transient elevation in blood pressure (BP) and heart rate (HR), poor balance, dizziness, blurred vision, double vision, tunnel vision, slurred speech, nausea, anticipatory anxiety, agitation and confusion.^21,26,27 Uncommon effects of ketamine include: vomiting, insomnia that night, headache, irritable bladder, loss of appetite and muscle tremors. In very rare cases of allergy to ketamine, laryngospasm is a possible adverse effect.^21,26,27 With low-dose lytic dosing, expected effects include slightly altered visual perception lasting approximately 15 min, relaxation and transient elevation in BP and HR; uncommon effects include mild transient nausea lasting approximately 10 min.^21,26,27

Available data suggest that KaT-related hypertension is expected and not concerning when treating normotensive or well-controlled hypertension patients.^28,29 Moreover, KaT-related hypertension tends to be in a similar range to BP elevations expected during exercise.^{29 –31} Existing data suggest stable or improving cognition levels with appropriate ketamine dosage. ²⁶ Notably, a recent study of 448 KaT sessions reported an absence of major adverse effects, indicating low adverse effect frequency. ²⁸ In addition, Tsang et al. ²⁸ demonstrated that effective prevention of adverse effects such as nausea, vomiting, anxiousness, and hypertension can be achieved with prophylactic medications.

Group therapy for treatment of eating disorders

Research into group therapy for the treatment of eating disorders is showing promise, particularly in terms of CBT provided in a group setting.^{8 –10,12,15,32,33} O’Connor et al. ⁹ found that while there are limited high-quality studies that examine group psychotherapy for eating disorders, the evidence that is available is efficacious, particularly in the case of BED.

Understanding communities of practice

The idea of a community of practice (CoP) was originally defined by Lave and Wenger ³⁴ as a like-minded community of individuals who choose to intentionally and consistently interact in a relational context to build a given skill set. ³⁵ This concept was the foundational basis for the evidence-informed version of a CoP program used at roots to thrive (RTT) for the purpose of addressing mental health conditions that have been difficult to treat through first-line approaches. ³⁵ Since 2019, the RTT program has operated within a defined CoP structure to deliver ketamine and psilocybin-assisted group therapy. ²⁷ The CoP framework aims to foster resilience through the development of congruence ³⁶ and a sense of coherence ³⁷ alongside co-regulation, as informed by polyvagal theory. ³⁸ CoP-based group therapy focuses on fostering somatic awareness and self-compassion to improve mental health outcomes, nervous system regulation, and resilience.^11,27,35,39 Similarly, RTT’s CoP approach focuses on resilience development through four core practices: awareness development, regulation, connection through compassion, and alignment with purpose.^28,35,39 Participants are thoroughly prepared and supported prior, during, and post all therapeutic sessions. ²⁷

Implementing group PaT in a CoP setting

Given the efficacy of PaT in treating comorbid conditions and the complexity of eating disorder treatment, researchers are calling for more studies exploring PaT for eating disorders.^{5,40 –42} The addition of KaT to group therapy provides a window of increased neural plasticity, enabling individuals to process uncomfortable emotions and develop a healthier relationship with food. ¹¹ Combining KaT with group therapy fosters resilience, self-compassion, and perspective shifts.^11,35

Offering PaT within a CoP setting creates a safe environment where individuals can process their traumas and develop an intuitive relationship with food. This approach fosters a sense of belonging and shared healing, which is crucial for individuals with disordered eating patterns.^2,3,35 CoPs provide a structure for integrating the insights gained through PaT, promoting long-term resilience and cognitive flexibility.^27,35

Combining PaT with a CoP structure can facilitate significant personal transformation by providing a supportive relational space for processing emotions and developing healthier eating habits. PaT-induced cognitive shifts allow individuals to replace rigid thought patterns with more adaptive and flexible responses to their environment.^{2,11,16,27,35}

In conclusion, combining PaT with group therapy, particularly within a CoP setting, presents a promising new direction for treating eating disorders. PaT has the potential to enhance cognitive flexibility, emotional resilience, and self-compassion, which are key factors in overcoming disordered eating patterns. Future research should continue to explore the synergistic effects of these therapeutic modalities, with a focus on addressing the underlying traumas and comorbid conditions that often accompany eating disorders.^2,3,35