Abreactive ketamine psychotherapy (historical)

1. Introduction

Version followed: Khorramzadeh & Lotfy (1973), "The Use of Ketamine in Psychiatry", Psychosomatics 14:344–346 (Shiraz, Iran; 100 inpatients), read in full via the MAPS bibliography copy; secondary context from Mathai, Mora & Garcia-Romeu (2022) and Drozdz et al. (2022). Present-day frame from regulator, clinic-consent and memory-research sources listed below.

HISTORICAL — NOT FOR USE. This tab describes a 1970s inpatient research procedure so that clinicians can recognise it, place historical and present-day claims about it, and support clients. It is not a protocol. No doses, routes, rates or schedules of administration are given, deliberately. Any drug component of ketamine treatment today belongs to licensed medical prescribers in regulated settings.

What it was. Psychiatrist Enayat Khorramzadeh and anaesthesiologist Atta Ollah Lotfy, at a university hospital psychiatric unit in southern Iran (Shiraz), gave the dissociative anaesthetic ketamine to 100 psychiatric inpatients while a psychiatrist observed and, if needed, verbally prompted them, aiming to produce an abreaction: an intense emotional discharge accompanied by verbalised conflict and the recall of emotionally charged, often childhood, material. They described it as, to their knowledge, "the first investigation into the use of this chemical as an abreactive agent" [source: Khorramzadeh & Lotfy 1973]. Later reviews credit it as the first report that ketamine could facilitate psychotherapy [source: Drozdz et al. 2022; Mathai et al. 2022].

Core idea of change (as published). The authors treated ketamine's dissociative "emergence phenomenon" (the dreamlike, disinhibited state as anaesthetic effects wear off) as a tool for opening the mind: emotional discharge and the surfacing of repressed or conflict-laden material were taken to unlock the patient's psychotherapy, with the material then used in later interviews and interpretation [source: Khorramzadeh & Lotfy 1973]. This is the classic cathartic-abreaction model inherited from barbiturate narcoanalysis/narcosynthesis, in which a drug lowers inhibition so patients will recall and talk about traumatic material [source: Wikipedia, Narcosynthesis]. Mathai et al. (2022) summarise the Iranian work as ketamine given during abreactive psychotherapy for recalling and processing traumatic memories [source: Mathai et al. 2022].

Why it matters now. Ketamine is again used in psychiatry (esketamine is licensed; racemic ketamine is used off-label, sometimes with psychotherapy as "KAP"). Some marketing and some clients still frame ketamine as a way to "unlock" buried memories. The memory-research literature shows that drug-assisted recall can produce confidently held but false beliefs of abuse [source: Otgaar et al. 2025]. Knowing what the 1973 procedure was, what it claimed and what it could not show is the practical point of this tab [synthesis].

2. Framework

2a. The 1973 procedure as published (historical, not for use)

The paper describes a single-arm clinical series, not a staged therapy. Its phases, in general terms [source: Khorramzadeh & Lotfy 1973]:

• Session count: most patients had a single drug-assisted session; two asked for and received a second at follow-up, and the two non-improvers at one year were given a repeat session with reported short-lived relief [source: Khorramzadeh & Lotfy 1973].
• Criteria for moving on: none were defined beyond the presence or absence of an observed abreaction; "doing well" at follow-up was not operationalised [source: Khorramzadeh & Lotfy 1973; the absence of defined criteria is my reading of the paper].
• What was claimed: psychotherapy was facilitated and symptoms improved in essentially all responders; 91 of 100 "doing quite well" at 6 months; at 1 year, 88 still followed, all but two doing well; the authors called ketamine "a safe psychotomimetic agent" [source: Khorramzadeh & Lotfy 1973].
• Design limits: as read in the paper, there was no comparison group, no blinding and outcome was the clinicians' own judgement [source: Khorramzadeh & Lotfy 1973]. Mathai et al. (2022) describe the series as non-randomised; their wording on whether it was controlled differs from the paper as I read it [uncertain].
• A follow-up study by the same group reportedly related personality dimensions (extraversion, neuroticism, psychoticism) to the drug experience [source: Mathai et al. 2022; original uncertain].

2b. Why the practice stopped

No source opened states why the Shiraz work was not continued; Mathai et al. (2022) and Drozdz et al. (2022) both note it without explaining its end [uncertain]. Documented contextual factors that plausibly contributed [synthesis, from sources cited]:

• Drug-assisted abreaction as a whole (narcoanalysis/narcosynthesis) became "extraordinarily rare" amid debate over efficacy, doubts about the reliability of material recalled under drugs, raised suggestibility, ethical concerns and misuse in interrogation [source: Wikipedia, Narcosynthesis].
• Recreational ketamine use grew from the 1970s onward, leading to controlled-drug status (US Schedule III from August 1999; UK Class C 2006, Class B 2014) [source: Wikipedia, Ketamine in society and culture]. In Russia, rescheduling ended Krupitsky's separate ketamine psychotherapy research [source: Mathai et al. 2022].
• Later memory research showed drug-assisted recovery of "repressed" abuse can produce false beliefs [source: Otgaar et al. 2025].
• The sources do not say whether political change in Iran after 1979 played a role [uncertain].

2c. The regulated frame that exists today (for orientation and referral only)

The 1973 procedure has no current licensed equivalent. Present-day ketamine treatment, where clients may meet it [source: Psychiatric Times 2026; Field Trip KAP consent 2021; Drozdz et al. 2022; NICE via LSCMMG]:

• United States: ketamine is Schedule III. Esketamine (Spravato) is FDA-approved for treatment-resistant depression (2019) and for depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behaviour (2020); it may only be given in REMS-certified settings whose staff can manage physiological and dysphoric reactions, with medical monitoring and a post-session observation period handled by medical staff. Racemic ketamine for psychiatric indications is off-label; regulators do not govern off-label prescribing, and gaps in compounding, telehealth and monitoring rules have been described [source: Psychiatric Times 2026; Wikipedia, Ketamine in society and culture].
• United Kingdom: ketamine is Class B (since 2014, citing chronic bladder and urinary-tract harms) [source: Wikipedia, Ketamine in society and culture]. NICE TA854 does not recommend esketamine for treatment-resistant depression; local NHS formularies list it as not for NHS prescribing [source: LSCMMG].
• Elsewhere: Canada Schedule I (since 2005); Australia Schedule 8; the WHO Expert Committee decided in 2012 that international control was not appropriate [source: Wikipedia, Ketamine in society and culture; drugpolicyfacts.org/UNODC]. Iran's current status was not found [uncertain].
• Off-label KAP format (one clinic's published consent, 2021): intake with medical, psychiatric and psychological screening; a meeting with prescriber and therapist; ketamine sessions with the patient lying down, eye mask and music, a medical practitioner on site throughout and responsible for monitoring and emergency care; integration therapy sessions; escort home and no driving after sessions [source: Field Trip KAP consent 2021]. Across studies, KAP is psychotherapy before, during and/or after ketamine, with preparation, integration and sometimes two therapists present; CBT, exposure (including prolonged exposure for PTSD) and mindfulness-based approaches are the commonest pairings [source: Drozdz et al. 2022].

3. Guiding principles

A. Principles implicit in the 1973 procedure (historical, stated so you can recognise them):

• Catharsis heals. Emotional discharge itself was treated as therapeutic. Practical meaning today: treat any claim that "releasing" emotion under a drug is the active ingredient as a historical belief, not an established mechanism [source: Khorramzadeh & Lotfy 1973; synthesis].
• The drug reveals hidden material. The emergence state was used to bring up repressed conflict. Practical meaning: material surfacing under a dissociative drug is a psychological experience to explore, not a verified memory [source: Khorramzadeh & Lotfy 1973; Otgaar et al. 2025].
• Clinician-led elicitation. Where no abreaction occurred, the psychiatrist prompted it. Practical meaning: prompting under altered states increases suggestion risk; avoid leading content [source: Khorramzadeh & Lotfy 1973; Wikipedia, Narcosynthesis; Otgaar et al. 2025].
• Two-discipline team. A psychiatrist and an anaesthesiologist shared the session. Practical meaning: medical and psychological responsibilities were split, which remains the norm in regulated ketamine settings [source: Khorramzadeh & Lotfy 1973; Field Trip KAP consent 2021].

B. Principles for a clinician using this knowledge today [synthesis unless sourced]:

• Not for use. Never offer, arrange or simulate drug-assisted abreaction; the clinician's role is assessment, education, referral and integration.
• Memory humility. Experiences recalled or "seen" under drugs may be beliefs rather than memories; neither confirm nor dismiss, explore [source: Otgaar et al. 2025].
• No suggestion of hidden trauma. Do not propose abuse or repressed memories the client has not reported [source: Otgaar et al. 2025].
• Stabilise before processing. Trauma memories are worked with in a paced, client-controlled way, not provoked into overwhelming discharge [synthesis].
• Stay in role. Medical eligibility and monitoring belong to prescribers; the therapist screens psychologically, shares concerns and refers [source: Field Trip KAP consent 2021; Psychiatric Times 2026].
• Harm reduction without facilitation. For clients using ketamine outside clinics, focus on safety, risks in general terms and referral; never advise on obtaining or using it [synthesis].
• Document carefully. Clear records of what clients reported, and when, protect clients and allow later review of how beliefs formed [source: Otgaar et al. 2025].
• Respect the client's account of their history. Clients who went through drug-assisted therapies may feel helped, harmed or both; validate the experience without endorsing the method [synthesis].

4. Intervention inventory

Part A lists every component of the 1973 procedure as the paper reports it, as history, not for use (no drug details). Part B lists what a clinician does with this knowledge today. All Part B example language is illustrative; no wording is attributed to Khorramzadeh or Lotfy, whose paper gives no therapist scripts.

Part A. Components of the 1973 procedure (historical, not for use)

A1. Patient selection and exclusion (historical)

• Purpose (as published): pick inpatients thought suitable for abreaction [source: Khorramzadeh & Lotfy 1973].
• What was done: drawn from a university psychiatric inpatient unit; adults and older adolescents; organic brain syndrome and psychosis excluded; a broad mix of "neurotic", conversion, depressive and psychosomatic presentations (including ulcerative colitis and tension headache) included [source: Khorramzadeh & Lotfy 1973].
• Example language: none published.
• Watch for (today's reading): no trauma history was required for inclusion, so "recalled" material was sought in patients with no stated trauma; psychosomatic conditions were treated as if they had a recoverable psychological cause [synthesis]. The exclusion of psychosis matches modern ketamine screening, which also excludes psychosis history, active mania and substance-use disorder [source: Field Trip KAP consent 2021].

A2. Explanation of the technique and written consent (historical)

• Purpose: inform patients and record agreement [source: Khorramzadeh & Lotfy 1973].
• What was done: each patient was given an overview of the technique and signed a consent form. The paper gives no detail on what risks, alternatives or memory-related uncertainties were explained [source: Khorramzadeh & Lotfy 1973; content of the explanation not reported, uncertain].
• Example language: none published.
• Watch for (today's reading): inpatient status and a doctor-led proposal can limit how freely consent is given; modern consent for ketamine treatment covers risks, alternatives, off-label status and the right to withdraw [source: Field Trip KAP consent 2021; synthesis].

A3. Observed drug-assisted session aiming at abreaction (historical)

• Purpose (as published): use the dissociative emergence state to provoke emotional discharge and the verbalising of conflict [source: Khorramzadeh & Lotfy 1973].
• What was done, in general terms: the patient lay down in a medical setting; the anaesthesiologist co-author was present for the drug phase and handled medical aspects, including simple checks of the level of drug effect; a psychiatrist observed throughout. Abreaction was recognised by excitement, emotional discharge, verbalisation of conflict and emergence phenomena. When patients did not respond, the authors changed the drug condition in a later group (details deliberately omitted) [source: Khorramzadeh & Lotfy 1973].
• Example language: none published.
• Watch for (today's reading): the target state was one of disorientation, temporary loss of contact and hallucinatory experience, i.e. reduced capacity to evaluate what was being recalled or suggested [source: Khorramzadeh & Lotfy 1973; Otgaar et al. 2025; synthesis].

A4. Verbal prompting when no spontaneous abreaction occurred (historical)

• Purpose (as published): elicit abreaction in patients who did not produce it spontaneously [source: Khorramzadeh & Lotfy 1973].
• What was done: the observing psychiatrist prompted verbally; the paper does not report the wording or topics [source: Khorramzadeh & Lotfy 1973; content not reported].
• Example language: not published; do not reconstruct.
• Watch for (today's reading): prompting during a drug-induced state of heightened suggestibility is the specific feature most linked to false beliefs in the narcoanalysis literature; in Otgaar et al.'s case, a psychiatrist's interpretation of drug-state imagery as signs of abuse led to a belief later retracted [source: Otgaar et al. 2025; Wikipedia, Narcosynthesis].

A5. Immediate post-session debrief interview (historical)

• Purpose (as published): make what emerged available for later interview and interpretation [source: Khorramzadeh & Lotfy 1973].
• What was done: as the state cleared, patients were asked what had happened and how they felt, given encouragement where needed and asked about "mind-expanding" experiences; most then rested or slept [source: Khorramzadeh & Lotfy 1973].
• Example language: none published.
• Watch for (today's reading): interpretation offered right after a dissociative state can fix a narrative before the person can question it; modern integration work is client-led and paced [source: Drozdz et al. 2022; Otgaar et al. 2025; synthesis].

A6. Follow-up review and repeat sessions (historical)

• Purpose: judge outcome [source: Khorramzadeh & Lotfy 1973].
• What was done: reviews at 6 and 12 months; outcome recorded as "doing well" or not, without stated criteria; repeat sessions for a few patients on request or for non-improvement [source: Khorramzadeh & Lotfy 1973].
• Example language: none published.
• Watch for (today's reading): clinician-rated, undefined outcomes without comparison cannot separate drug, inpatient care, ongoing therapy and natural recovery [synthesis].

A7. Handling adverse reactions (historical)

• Purpose: manage session complications [source: Khorramzadeh & Lotfy 1973].
• What was reported: temporary loss of contact, disorientation and hallucinatory experiences; excitement; prolonged dizziness in one patient; nausea and vomiting in a few; apprehension or severe depersonalisation in two, whose sessions the medical team ended early with medication; prolonged abreaction or altered state lasting over two hours in four [source: Khorramzadeh & Lotfy 1973].
• Example language: none published.
• Watch for (today's reading): the authors' conclusion that the drug was "a safe psychotomimetic agent" rests on their own uncontrolled observation; severe depersonalisation and prolonged states are exactly the reactions modern clinics require medical staff to manage [source: Khorramzadeh & Lotfy 1973; Psychiatric Times 2026; synthesis].

Part B. What a clinician does with this knowledge today

B1. Recognising historical and present-day "abreactive" claims

• Purpose: identify when a client, colleague, clinic or self-help source is reviving the drug-assisted abreaction model, so you can respond accurately [synthesis].
• Steps:
  1. Listen for the model's markers: ketamine (or another drug) presented as a way to "unlock", "release" or "uncover" repressed or hidden memories; emotional discharge treated as the cure; a practitioner who interprets imagery as evidence of past events; a promise that one or a few sessions resolve longstanding symptoms [source: Khorramzadeh & Lotfy 1973; Wikipedia, Narcosynthesis; Otgaar et al. 2025; markers as a checklist are synthesis].
  2. Place it: tell the client this approach was tried in the 1970s and in earlier barbiturate narcoanalysis, that its results came from uncontrolled reports, and that it is not part of licensed ketamine treatment [source: Khorramzadeh & Lotfy 1973; Drozdz et al. 2022; Psychiatric Times 2026].
  3. Distinguish it from regulated care: licensed esketamine or off-label ketamine with psychotherapy is offered with medical screening, monitoring and integration, and uses established therapies (e.g. CBT, exposure, mindfulness) rather than provoked catharsis [source: Drozdz et al. 2022; Field Trip KAP consent 2021].
• Example language (illustrative): "The idea that ketamine can open up buried memories has a history going back to the 1970s. It was never properly tested, and memory researchers have found drug states can make people more suggestible. Licensed ketamine treatment today isn't designed to recover memories."
• Watch for: the client feeling dismissed if they have found ketamine helpful; separate the drug's possible benefits from the memory-recovery claim [synthesis]. It is working when the client can weigh a clinic's claims critically.

B2. Assessing a client who went through drug-assisted abreaction or narcoanalysis

• Purpose: understand what happened, what it means to the client and whether it left harms (e.g. distress, dissociation, family estrangement, contested beliefs about abuse) [source: Otgaar et al. 2025; synthesis].
• Steps [synthesis]:
  1. Ask open questions about when, where, who, what they were told beforehand, what they experienced and how it was interpreted to them.
  2. Ask what they believed afterwards, how sure they are, and whether the belief came with specific memories or only with a sense that "something happened" (belief without memory is described in the case literature) [source: Otgaar et al. 2025].
  3. Screen for current PTSD, dissociative, depressive and substance-use symptoms, and current suicide risk using standard assessment.
  4. Map effects on relationships (e.g. estrangement after accusations) [source: Otgaar et al. 2025].
  5. Ask what the client wants now: understanding, symptom relief, help with family, or none of these.
• Example language (illustrative): "Can you tell me what that treatment was like, in your own words? What were you told it would do, and what did you make of it afterwards?"
• Watch for: shame, anger at former clinicians, or loyalty to them; do not rush to call the treatment harmful or helpful. Working when the client can tell the story at their own pace without overwhelm.

B3. Non-suggestive exploration of memories or beliefs formed under drug states

• Purpose: help a client think about material that emerged under ketamine, narcoanalysis or another drug state without confirming or implanting content [source: Otgaar et al. 2025; synthesis].
• Steps:
  1. Use open, non-leading questions; do not name possible perpetrators or events the client has not named [source: Otgaar et al. 2025].
  2. Separate three things with the client: what they experienced in the session (images, feelings), what they were told it meant, and what they now believe [source: Otgaar et al. 2025, belief-versus-memory distinction; the three-way split is synthesis].
  3. Explain, neutrally, that drug states can raise suggestibility and that confidence is not proof of accuracy; that some such experiences reflect real events and some do not [source: Otgaar et al. 2025; Wikipedia, Narcosynthesis].
  4. Invite the client to consider what other information, if any, they would want (records, family accounts), without pushing them to seek it; external information was the turning point in the published retraction case [source: Otgaar et al. 2025].
  5. Keep the focus on current functioning and goals; the therapy does not need to settle what happened in order to help [synthesis].
• Example language (illustrative): "What you saw and felt in that session was real as an experience. What it says about your past is a separate question, and we don't have to decide that today. What did you take from it at the time, and how do you see it now?"
• Watch for: your own pull to interpret; sudden increase in certainty after sessions with you; family conflict escalating. Working when the client holds the question with less distress and can tolerate uncertainty.

B4. Memory-safety informed-consent conversation before any ketamine referral

• Purpose: ensure a client considering ketamine treatment understands that it is not a memory-recovery method and that distressing material may arise [source: Field Trip KAP consent 2021; Otgaar et al. 2025].
• Steps:
  1. Ask what the client hopes ketamine will do; listen for "unlock" or "find out what happened" goals [synthesis].
  2. Explain that licensed and off-label ketamine treatments are offered for conditions such as depression, that consent forms list uncomfortable feelings or troubling memories as possible effects, and that such material is to be processed carefully, not treated as proof [source: Field Trip KAP consent 2021; Psychiatric Times 2026; Otgaar et al. 2025].
  3. Agree how any material that emerges will be handled with you (pace, grounding, no interpretations imposed) [synthesis].
  4. Note the general practical rules clinics require (escort home, no driving, defer major decisions) without discussing drug details [source: Field Trip KAP consent 2021].
  5. Document the conversation [source: Otgaar et al. 2025].
• Example language (illustrative): "Some people find old memories or strong feelings come up during ketamine sessions. If that happens, we'll take it slowly together and treat it as something to understand, not as a verdict on your past."
• Watch for: a client set on proving a specific event; consider whether ketamine treatment fits their goals and discuss with the prescriber. Working when the client can state realistic expectations.

B5. Psychological screening and referral to regulated ketamine care

• Purpose: contribute the psychological picture to a prescriber's eligibility decision and route the client to regulated care [source: Field Trip KAP consent 2021; Psychiatric Times 2026].
• Steps:
  1. Note conditions that published clinic criteria treat as exclusions or cautions, to share with the prescriber: history of psychosis or schizophrenia (and close family history), active mania or hypomania, current substance-use disorder or past ketamine addiction, pregnancy or nursing; plus medical issues the prescriber will assess (poorly controlled blood pressure or heart problems, hyperthyroidism, severe respiratory disease or sleep apnoea, recent brain injury or dementia, prior bad reaction) [source: Field Trip KAP consent 2021].
  2. Add trauma-specific observations: severity of dissociation, current stability, safety, and support at home [synthesis].
  3. Explain the difference between licensed esketamine (certified settings under REMS in the US; not recommended by NICE for NHS use in the UK) and off-label ketamine, and that the prescriber decides medical suitability and conducts monitoring [source: Psychiatric Times 2026; LSCMMG/NICE TA854].
  4. Send a written referral with consent; agree who provides integration therapy [synthesis].
• Example language (illustrative): "I can share what I know about your history with the prescriber; they'll decide whether it's medically suitable and what the safest setting is."
• Watch for: clinics without on-site medical staff or screening, or that promise memory recovery; refer elsewhere [source: Field Trip KAP consent 2021; Psychiatric Times 2026; synthesis].

B6. Integration support after distressing material emerges in a ketamine session

• Purpose: help the client stabilise and make sense of the experience, which is the post-session therapy role in modern KAP [source: Drozdz et al. 2022; Mathai et al. 2022].
• Steps [synthesis unless sourced]:
  1. Start with safety and stabilisation: sleep, support, current risk, grounding skills (e.g. orienting to the room, paced breathing).
  2. Invite a free account; reflect rather than interpret (see B3) [source: Otgaar et al. 2025].
  3. Identify what the client wants to carry forward into daily life (insights, intentions) [source: Drozdz et al. 2022 on integration].
  4. If trauma memories are involved, move to a paced, evidence-based trauma approach (B8) rather than repeating provoked catharsis.
  5. Feed back concerns to the prescriber (e.g. persisting dissociation, worsening suicidal thoughts, signs of psychosis) [source: Field Trip KAP consent 2021].
• Example language (illustrative): "Let's first check how you've been since the session. Then, if you want, tell me about it in whatever order makes sense; I'll mostly listen."
• Watch for: persisting depersonalisation, intrusive memories, worsening mood or suicidal thinking: escalate per standard risk practice and inform the prescriber. Working when the client is grounded and can link the experience to present goals.

B7. Harm reduction and integration for clients using ketamine outside clinics

• Purpose: reduce risk for clients who use ketamine non-medically, including people trying self-directed "trauma release", without facilitating use [synthesis].
• Steps:
  1. Assess non-judgementally: context, frequency in general terms, purpose (e.g. self-treatment of trauma), effects, dependence signs [synthesis].
  2. Educate in general terms about documented risks: dissociation and impaired coordination, anxiety and fright, raised blood pressure, worsening psychotic or suicidal symptoms, abuse and dependence potential, and chronic bladder and urinary-tract damage with heavy use; memory and attention problems reported with chronic heavy use [source: Field Trip KAP consent 2021; Wikipedia, Ketamine in society and culture; Jansen 1990].
  3. Mention general safety points: not using alone, not driving, and that interactions with other substances and medications should be discussed with a doctor [source: Field Trip KAP consent 2021 on driving and interactions; rest synthesis].
  4. Note legal status in their jurisdiction (controlled drug in the US, UK, Canada, Australia) [source: Wikipedia, Ketamine in society and culture].
  5. Offer referral to medical, addiction or regulated psychiatric care; build a safety plan [synthesis].
• Example language (illustrative): "I'm not going to advise you on using it, but I do want you to be safe. Can we talk about what you're hoping it does for the trauma, and what else might get you there?"
• Watch for: urinary symptoms, escalating use, using alone, dissociation persisting between uses. Working when the client engages with safer care.

B8. Referral to or delivery of evidence-based trauma therapy

• Purpose: offer the trauma processing that abreaction aimed at, through approaches that are paced and tested [synthesis].
• Steps [synthesis]:
  1. Assess for PTSD and complex presentations with standard instruments.
  2. Offer an established trauma-focused therapy you are trained in (e.g. prolonged exposure, cognitive processing therapy, EMDR, trauma-focused CBT), or refer. Prolonged exposure has also been studied combined with ketamine in regulated research [source: Drozdz et al. 2022].
  3. Use a phase-oriented approach (stabilisation first) where dissociation or instability is high.
• Example language (illustrative): "There are therapies built to help with traumatic memories at a pace you control. Let me explain how they work."
• Watch for: symptom worsening without recovery between sessions; adjust pace. Working when intrusions and avoidance decrease over sessions.

5. Handling problems

Most of this section is synthesis: the 1973 paper gives no guidance on problems beyond the adverse reactions in A7.

• Client insists ketamine will unlock a repressed memory. Explore the hope behind it (to make sense of symptoms, to be believed); explain neutrally the history and memory research (B1, B3); keep the therapy goal on present symptoms; discuss with the prescriber whether treatment fits [source: Otgaar et al. 2025; synthesis].
• Client is distressed by a belief formed in past drug-assisted therapy (possible false belief). Do not confirm or debunk; use B3; consider the family impact; if the client starts to doubt the belief, support them through grief, guilt and repair of relationships, which retractors describe [source: Otgaar et al. 2025; synthesis].
• Client feels harmed by a former clinician's drug-assisted treatment. Validate the experience; inform them of complaint routes to professional regulators; document; consider your own reporting duties if a current practitioner is involved [synthesis].
• Overwhelm or prolonged dissociation after a ketamine session. Ground and stabilise; assess risk; contact the prescriber; urgent care or emergency services if severe or if psychotic or suicidal symptoms appear [source: Field Trip KAP consent 2021 on reporting and crisis routes; synthesis].
• Stuck after ketamine treatment (no change, or repeated sessions sought). Review goals; check for avoidance via the drug; move to structured trauma therapy (B8); share concerns about escalation with the prescriber [synthesis].
• Non-adherence or ambivalence about integration sessions. Shorten sessions, focus on practical goals, and agree a minimum check-in after each ketamine session [synthesis].
• Rupture (client wants you to endorse the abreaction model or a recovered memory and you do not). Name the disagreement; affirm their experience and your commitment; explain your caution as care, not disbelief [synthesis].
• Colleague or clinic offering ketamine-assisted "memory recovery" or catharsis. Raise concerns collegially; check medical oversight and consent; if clients are being harmed or practice is outside licensing, follow your professional body's reporting procedures [synthesis].
• Client using ketamine outside clinics for self-treatment. Apply B7; assess for dependence and bladder symptoms; refer to medical and addiction care [source: Wikipedia, Ketamine in society and culture; Field Trip KAP consent 2021; synthesis].
• Suicidal ideation emerging during or after ketamine treatment. Standard risk assessment and safety planning, lethal-means counselling (safe storage and removal), liaison with the prescriber; worsening suicidal thoughts are a listed risk [source: Field Trip KAP consent 2021; synthesis].

Sources

Sources:

• Khorramzadeh E, Lotfy AO (1973). The Use of Ketamine in Psychiatry. Psychosomatics 14:344–346 (MAPS bibliography copy)
• Mathai DS, Mora V, Garcia-Romeu A (2022). Toward Synergies of Ketamine and Psychotherapy. Frontiers in Psychology
• Drozdz SJ et al. (2022). Ketamine Assisted Psychotherapy: A Systematic Narrative Review of the Literature. Journal of Pain Research 15:1691–1706
• Otgaar H et al. (2025). A Case Study on Drug-Assisted Psychotherapy and Recovering and Retracting Beliefs of Abuse. J Forensic Psychology Research and Practice
• Field Trip Health (2021). Ketamine-Assisted Psychotherapy Patient Information & Consent Package (via ClinicalTrials.gov)
• Psychiatric Times (2026). Esketamine, Off-Label Ketamine, and the Regulatory Gap: interview with Lisa Harding, MD
• Lancashire & South Cumbria Medicines Management Group. Esketamine (Spravato) formulary entry, NICE TA854 status
• Wikipedia. Ketamine in society and culture (legal status)
• Wikipedia. Narcosynthesis
• Drug Policy Facts. History of Ketamine and Control Efforts (citing UNODC 2013)
• Jansen KLR (1990). Ketamine: Can Chronic Use Impair Memory? Int J Addictions 25:133–139 (MAPS copy)
• Kolp E et al. (2014). Ketamine Psychedelic Psychotherapy. Int J Transpersonal Studies 33(2) (abstract page only)

Further reading (not drawn on; cited via secondary sources, uncertain): the Khorramzadeh & Lotfy follow-up study on personality and ketamine response (cited in Mathai et al. 2022); NICE TA854 full text.