Ketamine plus psychotherapy pairings

Domain VII · Transpersonal, psychedelic & altered states · Wilkinson, Rodriguez, Harpaz-Rotem · 2016

What it is

What it is: a psychotherapist delivers a standard structured therapy in a planned relationship to ketamine or esketamine sessions run by medical staff. The ketamine is not the therapy. Here it is used as a possible "enhancer" or "facilitator" of the psychotherapy, unlike the psychedelic-style…

Format

• Therapy engagement and preparation. This is the first therapy session(s): rationale, goals, treatment planning, preparation for possible drug-session experiences.
• Ketamine-paired phase. Therapy sessions are placed before and/or after the medical team's ketamine sessions, as the protocol specifies. The psychological work is done when the acute drug effects have worn off, not during them (VA PE protocol: no psychological intervention or directives while acute…

Who practises it, and how they are trained or regulated

• United States: esketamine (Spravato) is FDA-approved for adults with treatment-resistant depression and for depressive symptoms in MDD with acute suicidal ideation or behaviour. It is Schedule III and available only under the Spravato REMS: enrolled providers, use in a certified healthcare setting, and post-administration monitoring by staff who can complete the required assessments. A January 2025 FDA approval of…
• United Kingdom: esketamine was licensed for TRD (December 2019) and is a Schedule 2 controlled drug with a mandatory patient register (from April 2022). The Scottish Medicines Consortium accepted it (2020). NICE did not recommend it (TA854, 2022). Racemic ketamine is unlicensed for depression; a few NHS trusts use it off-label and private clinics exist. MORE-KARE is a UK phase III NIHR-funded trial, recruiting from…
• Therapist: delivers the manualised therapy. Depending on protocol, the therapist also prepares the client, gives supportive presence (KARE) or mindfulness-based relaxation as a "sitter" (NYSPI) during the session, and debriefs. Therapists were licensed doctoral or master's psychologists (VA), Beck Institute-certified CBT therapists (Yale CBT), trained psychologists delivering both arms (KARE), and MET-trained…

Evidence status, as the guide reports it

• Into CBT (Yale): response to the ketamine phase is the gate. Non-responders were not randomised.

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• avoidance of the actual problem.
• blank journals. Simplify the format.
• activities that bring back drinking cues.
• stopping all exposures once acute relief fades.
• residual avoidance items. Working: CAPS-5/PCL-5 improvement.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.