Atlas›Domain VII · Transpersonal, psychedelic & altered states›Guide 047
Guide VII-047

Ketamine-assisted psychotherapy (KAP)

Eli Kolp, Phil Wolfson, Jennifer Dore2007
A 35 · L 48 · M 1720 interventions in the Trinity explorer1 described for recognition only
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the office-based community KAP model described by Dore, Wolfson and colleagues (Dore et al., 2019, Journal of Psychoactive Drugs: Helios Psychiatry, Woodside CA; Roots Behavioral Health, Austin TX; Center for Transformational Psychotherapy and Ketamine Research Foundation, San Anselmo CA). Two published frames supplement it: the group format of the Roots To Thrive community-of-practice protocol (Dames, Kryskow, Tsang & Argento, 2025, Canada) and the prescriber-plus-therapist collaborative care model from Journey Clinical training material hosted by the APA. Kolp's ketamine psychedelic psychotherapy (KPP) and its forerunner, Krupitsky's ketamine psychedelic therapy (KPT) for alcoholism, are covered as lineage; Kolp's technique is taken from his 2014 guide and from the 2007 death-anxiety case reports (Kolp et al.). The Canadian prescribing statement (Dames et al.), the Australian TGA decision and NICE's 2020 draft decision on esketamine are from primary or near-primary sources; the EU approval rests on a secondary news report; Roots To Thrive's full exclusion list sits in a supplementary medical protocol that is not reproduced here [uncertain].

What it is. Ketamine-assisted psychotherapy (KAP) is not a single manualised therapy. It is a family of practices in which psychotherapy (preparation, accompaniment during a ketamine-induced altered state, and integration) is combined with ketamine prescribed and medically supervised by a licensed prescriber. In community practice this is mostly off-label racemic ketamine; esketamine (Spravato) is an FDA-approved alternative given only inside certified settings. Three lineages matter here:

  • Eli Kolp (private practice, Sarasota, Florida, per the 2014 author affiliations) and colleagues called their earlier work "ketamine-enhanced psychotherapy" (KEP). Kolp et al. (2007) reported two case studies of KEP for death anxiety in terminally ill hospice patients, using an assessment session, preparation sessions, one accompanied medicine session and an integration session (see 4.21). Kolp, Friedman, Krupitsky, Jansen, Sylvester, Young & Kolp (2014, International Journal of Transpersonal Studies 33(2), 84–140) is a guide for psychiatrists covering ketamine's pharmacology, the phenomenology of ketamine-induced states (which it groups as empathogenic, out-of-body, near-death and ego-dissolving transcendental experiences), the clinical literature on KPP, and possible harms of misuse. Its technique section follows Krupitsky's three stages: substantial preparatory psychotherapy that sets a psychospiritual goal, an attentively supervised session lying down with eyeshades and chosen music, and integration, preferably in a group; it calls the therapeutic relationship, set and setting "paramount". [source: Kolp et al., 2007; Kolp et al., 2014] The 2014 guide was reprinted as a chapter in Wolfson & Hartelius (Eds.), The Ketamine Papers (MAPS, 2016, pp. 97–198). [source: USF repository record] A practitioner article relaying the chapter reports that Kolp suggests near-death-like experiences may help "stable recovery" by accelerating psycho-spiritual growth. [source: Sienknecht, Chacruna, 2020 (secondary)]
  • Phil Wolfson founded the Ketamine Research Foundation, co-edited The Ketamine Papers (2016), and reports having trained roughly 900 therapists, mainly in methodology. [source: Duncan interview]
  • Jennifer Dore and co-authors published a retrospective chart analysis of 235 patients treated between 2013 and 2018 in three private psychiatry practices. [source: Dore et al., 2019]

How change is thought to happen. Dore et al. argue that the dissociative or psychedelic state is "an integral part of KAP" and that some degree of altered consciousness is needed for benefit. They describe the effects as a continuum running from a lighter "trance" state, suited to talking and meditative self-reflection, to a fuller "transformation" state with out-of-body and ego-dissolution qualities. Insights from these states are then "anchored" and carried into daily life through integration. [source: Dore et al., 2019] Plasticity-oriented models disagree on timing: they deliver structured psychotherapy (CBT, ACT, MBCT, motivational work) after the acute effects have passed, in a proposed window of neural adaptation. [source: Mathai, Mora & Garcia-Romeu, 2022] Wolfson's own framing is that psychedelics are not liberating in themselves and "had to be contextualized" by intention and setting. [source: Duncan interview]

Legal and regulatory status (US, Canada, Australia, UK and EU, as of the sources cited).

  • Ketamine is a Schedule III controlled substance. It has been FDA-approved as an anaesthetic since 1970, and prescribing it off-label for depression and anxiety is legal and common. [source: Journey Clinical/APA slides; Kolp et al., 2007 abstract]
  • Esketamine (Spravato, CIII) is approved for treatment-resistant depression in adults, with or without an oral antidepressant (label revised 09/2026). It is also approved, together with an oral antidepressant, for depressive symptoms in adults with MDD who have suicidal thoughts or actions. It is not approved for suicide prevention or in children. [source: FDA label 211243s026]
  • The Spravato REMS limits use to REMS-certified healthcare settings, requires outpatient settings to enrol patients, and requires a healthcare provider to monitor the patient during and after each treatment and decide when they may leave. Patients must not drive until the next day after restful sleep. [source: FDA label]
  • Canada: Dames et al. state that ketamine can be prescribed without special permissions from Health Canada, which is why Roots To Thrive uses it, whereas psilocybin and MDMA are provided only through special approvals. All ketamine sessions are medically supervised by licensed prescribers under provincial and federal clinical governance standards. [source: Dames et al., 2025] Health Canada's authorisation of esketamine is [uncertain].
  • Australia: the TGA approved esketamine (Spravato) on 5 March 2021, after an initial September 2020 decision was revoked on a section 60 appeal; it was entered on the ARTG on 9 March 2021. The indication is treatment-resistant depression in adults with MDD who have not responded adequately to at least two antidepressants in the current moderate-to-severe episode, started together with a newly initiated oral antidepressant. The patient uses it under the direct supervision of a healthcare professional and is observed afterwards; it carries a Black Triangle (additional monitoring) flag. [source: TGA AusPMD] The status of off-label racemic ketamine for psychiatric use in Australia was not verified. [uncertain]
  • UK and EU: a news report states that the European Medicines Agency approved esketamine in 2019 (unconfirmed against EMA documents). In February 2020 NICE issued draft guidance not recommending esketamine for NHS use in treatment-resistant depression, citing unclear benefit over other augmentation options, no comparison with psychological therapies, doubts about how long benefits last, and cost. NICE advises on NHS adoption; it does not license medicines. [source: Psychedelic Review, 2020 (secondary)] MHRA licensing, NICE's final position, later EU indication changes and the status of off-label ketamine in the UK and EU are unconfirmed. Check national regulators. [uncertain]

The therapist's scope throughout is the psychotherapy. Prescribing, administration, physiological monitoring and medical rescue belong to the medical team and are not described here. [source: Journey Clinical/APA slides; Dames et al., 2025]

2. Framework

Phases (common sequence across sources). [source: Journey Clinical/APA slides; Dore et al., 2019; Dames et al., 2025]

  1. Referral and medical/psychiatric evaluation (prescriber).
    • Goal: establish diagnosis, medical clearance and eligibility, and a treatment plan.
    • Dore et al.: a full DSM-based psychiatric evaluation, rater views of personality rigidity, and baseline scales (BDI, HAM-A, PHQ-9, Levine Depression Scale, ACE score, Childhood Resilience Scale).
    • Roots To Thrive: requires a referral from a licensed provider and runs PHQ-9, GAD-7, PCL-5 and B-IPF, a 45–60 minute nurse interview on trauma-informed readiness and capacity to co-regulate in a group, and a physician evaluation. Psychiatric evaluation is added if indicated.
  2. Preparation (therapist; ordinary-length sessions).
    • Goal: informed consent, expectations, intentions, trust, touch agreements, orientation to the session day.
    • Roots To Thrive also requires a group preparation session, a private physician consultation, and orientation to the room and playlist. All preparation must be finished before the first medicine session.
  3. Medicine (dosing) sessions, which run longer than ordinary sessions.
    • Dore et al. describe sessions of up to about three hours followed by supervised recovery. The first in-office session establishes the individual's response and which state (trance vs. transformation) is reliably reached. Medication decisions belong to the prescriber.
    • Dore et al.'s model also includes a supervised at-home component in which patients recreate at home the set and setting practised in the office. Whether there is any home component, and every medical arrangement for it, is solely the prescriber's decision. This guide describes only the therapist's psychological frame around it (4.15) and gives no frequency, amounts or administration details. [source: Dore et al., 2019; scope: synthesis]
  4. Integration (therapist; ordinary-length sessions, individual or group).
    • Goal: process the experience, anchor insights, and translate them into behaviour.
    • Dosing and integration repeat according to the prescriber's and therapist's joint treatment plan.
  5. Maintenance or relapse-prevention phase, then discharge.
    • Dore et al.: medicine sessions become less frequent or are aimed at preventing relapse.
    • Roots To Thrive: discharge repeats the intake measures, sends a summary to the referring provider, and offers alumni community-of-practice access and optional refreshers when clinically indicated.

Session count and format.

  • Dore et al.: the number of in-office medicine sessions varied widely between patients, and more sessions were associated with greater improvement. Treatment was individual, with two clinicians present when possible (a therapist plus an MD, NP or FNP); otherwise another therapist was on site.
  • Roots To Thrive: a 12-week group programme. Each weekly community-of-practice session has a large-group part (about 30–40 minutes) and a small-group part (about 70–90 minutes). Cohorts are 20–40 people in small groups of 6–9, led by facilitator dyads at about 1:3–4. A small number of medicine sessions are embedded, and their number and spacing are set by the protocol's physicians. Optional psychiatry groups, EFT workshops and family-and-friends groups are also offered.
  • Journey Clinical: does not specify a session number.

Criteria for moving between phases.

  • Into medicine sessions: medical clearance, consent and preparation complete, and readiness confirmed by the physician (Roots To Thrive). Roots To Thrive also requires attendance at the weekly sessions.
  • Continuing: symptom measures and clinician ratings of session quality (Dore et al.). Dore et al. also used session measures (Change of State, Mystical Experience Questionnaire, Ego Dissolution Index); these are described, not reproduced.
  • Toward maintenance: improvement on measures (Dore et al.).
  • Explicit numeric progression rules: none are published in the sources cited. [uncertain]

3. Guiding principles

[source: Dore et al., 2019 unless stated]

  • The relationship is central, especially for trauma. In practice: be reliable and compassionate. The bond is the main safety device in an altered state.
  • Be more human, intimate and disclosing, while "not needing" the patient. In practice: warmth and appropriate self-disclosure are welcome, but the therapist's needs (for gratitude, closeness or proof of success) stay out of the room.
  • The therapist supports the person "to find their own path." In practice: do not steer the content of the experience toward your own interpretations. Help the client make their own meaning.
  • A "nest in the Winnicott sense". In practice: build a warm, safe, predictable physical and relational space before every session.
  • The altered state is part of the treatment, not a side effect. In practice: prepare clients for dissociation, and treat its content as material to work with. Plasticity-oriented models instead treat the post-acute window as the main working period. Know which model your team follows. [source: Mathai et al., 2022]
  • "Ketamine is not for everyone." In practice: screen thoroughly, accept non-response, and do not push.
  • Watch consciousness and the observing self. In practice: note whether the client keeps some capacity to self-observe, and report it to the prescriber, who makes medication decisions.
  • Two-person teams. In practice: work in dyads where possible, one of them medical. Roots To Thrive uses facilitator dyads with complementary backgrounds. [source: Dore et al.; Dames et al., 2025]
  • Separate roles. In practice: the prescriber handles eligibility, prescribing and monitoring; the therapist handles preparation, accompaniment and integration. Work within your competence and get additional training. [source: Journey Clinical/APA slides]
  • Set and setting. In practice: attend deliberately to the client's mindset, expectations and intention, and to the room, music, lighting and your own presence. [source: Journey Clinical/APA slides]
  • Altered states increase suggestibility and vulnerability. In practice: keep tight boundaries around transference, countertransference and touch. Get explicit, revisited consent for any touch. [source: Journey Clinical/APA slides; Dames et al., 2025]
  • Intention and context. In practice: never offer ketamine as a stand-alone "break". Embed it in purpose and follow-up. [source: Duncan interview with Wolfson]
  • Ketamine as "an adjunctive catalyst". In practice: the psychotherapy or community carries the change; the medicine supports it. [source: Dames et al., 2025]
  • Rogerian congruence and unconditional positive regard; Antonovsky's sense of coherence. In practice: be genuine and non-judging, and help clients experience life as comprehensible, manageable and meaningful. [source: Dames et al., 2025]
  • Move at the pace of group trust; model vulnerability. In practice: facilitators share appropriately first and do not force disclosure. [source: Dames et al., 2025]
  • Relational accountability, cultural humility, trauma-informed care, co-regulation, compassionate witnessing. In practice: repair harms openly, defer to people who hold cultural authority (for example Elders, where invited), offer choice and control, and regulate your own nervous system as a resource for others. [source: Dames et al., 2025]
  • Deliberately non-manualised. In practice: follow a structure, but adapt the content to the group or person. [source: Dames et al., 2025]

4. Intervention inventory

The sources describe procedures at different levels of detail. Where a step is my own operationalisation of a published element, it is tagged [synthesis]. No medication amounts, routes, timing or administration steps are given anywhere in this guide: those are the prescriber's.

4.1 Collaborative intake and readiness assessment

  • Purpose: decide, with the prescriber, whether KAP is appropriate now. Eligibility is set case by case by the medical professional. [source: Journey Clinical/APA slides]
  • Steps:
    1. Confirm the medical and psychiatric evaluation has been done by the prescriber. In the Dore model this is a full DSM-based evaluation; in Roots To Thrive it is a nurse interview plus physician evaluation, with psychiatry if indicated.
    2. Collect baseline measures your team uses. Dore et al. used BDI, HAM-A, PHQ-9, ACE and a resilience scale; Roots To Thrive uses PHQ-9, GAD-7, PCL-5 and B-IPF. Use licensed instruments as licensed. [source: Dore et al.; Dames et al.]
    3. Explore past experience of non-ordinary states and substance use. The physician in Roots To Thrive asks about prior non-ordinary state experiences. [source: Dames et al.]
    4. Assess personality rigidity. Dore et al. note that people with very rigid structures (for example severe OCD or some personality disorders) may find the trance state difficult. [source: Dore et al.]
    5. Check the exclusions and cautions the sources list, and pass any concern to the prescriber:
      • Journey Clinical lists: uncontrolled hypertension; uncontrolled glaucoma; acute mania or mixed state; severe breathing problems; history of primary psychotic disorder; ketamine allergy; active or past ketamine use disorder; active suicidal ideation or severe decompensation; uncontrolled or active substance use disorder. Also to consider: pregnancy or trying to conceive, nursing, liver disease, cystitis, hyperthyroidism, extreme personality disorder, and relevant medications.
      • For esketamine the FDA label adds: aneurysmal vascular disease, arteriovenous malformation and history of brain bleeding as contraindications, with caution in cardiac or brain conditions and in people with a history of psychosis. [source: Journey Clinical/APA slides; FDA label]
    6. Assess life stability and support. Journey Clinical notes that people in crisis or instability, people unable to make sound decisions, and people in unsupportive environments may not benefit. For group work, also assess capacity to co-regulate in a group (Roots To Thrive). [source: Journey Clinical/APA slides; Dames et al.]
  • Example language (illustrative): "Before we decide anything, I'd like to understand what you hope ketamine might help with, and what you've already tried. Your prescriber will look at the medical side. I'll be thinking about whether this is a good moment in your life to do this kind of work."
  • Watch for: pressure to start fast; hidden substance use; a search for escape rather than engagement; unstable housing or no one to drive or support them afterwards. It is working when client, therapist and prescriber share one written plan. [synthesis]

4.2 Informed consent conversation

  • Purpose: voluntary, informed agreement that is revisited, not a one-off signature. [source: Journey Clinical/APA slides; Dames et al.]
  • Steps:
    1. Cover the elements Journey Clinical lists:
      • off-label status where applicable;
      • known risks and side effects;
      • how KAP differs from standard psychotherapy;
      • the separate roles of prescriber and therapist;
      • safety requirements (for example a driver and no driving afterwards);
      • the right to withdraw at any time.
    2. Add the esketamine-specific REMS points where relevant: treatment only in a certified setting, monitoring by staff who decide discharge, no driving until the next day after restful sleep. [source: FDA label]
    3. Use a readiness checklist and document consent, then revisit it during preparation. [source: Dames et al.]
    4. Discuss the possibility of difficult experiences. KPT patients reported "fear and even horror" at times. [source: Krupitsky & Grinenko, 1997]
  • Example language (illustrative): "You can stop at any point: before a session, during one, or between sessions. Saying no will never affect your therapy with me."
  • Watch for: consent given to please the therapist; misunderstanding of what "off-label" means; expectations of a cure. Ask the client to explain the plan back in their own words. [synthesis]

4.3 Preparation sessions: expectations, intentions, trust

  • Purpose: shape "set" and build the alliance that makes the altered state safe. [source: Journey Clinical/APA slides; Dore et al.]
  • Steps:
    1. Describe the range of possible experiences in plain words: dissociation, feeling detached from the body, changes in time and self-sense, a lighter dreamlike trance or a deeper state. Dore et al. use the terms trance and transformation; KPT patients were warned about unusual experiences such as detachment from the body. [source: Dore et al.; Krupitsky & Grinenko]
    2. Elicit intentions collaboratively and write them down. Journey Clinical lists setting expectations and reviewing intentions as core content. [source: Journey Clinical/APA slides]
    3. Explain session-day flow and safety procedures (Roots To Thrive covers rationale, expected effects, safety procedures and flow in a group session). Arrange the driver and aftercare. [source: Dames et al.]
    4. Agree a stance toward the experience. KPT asked patients to "surrender fully to the experience". A modern equivalent is an agreement to stay curious and let things come and go, with a pre-agreed signal for help. [source: Krupitsky & Grinenko] [the signal: synthesis]
    5. Co-create the client's own story of what keeps their problem going and what helps. KPT built an individual "psychotherapeutic myth" through dialogue rather than lecture; Kolp et al. (2014) keep this step, together with exploring the client's motives for treatment, goals, and beliefs about the cause and consequences of the problem, and agreeing a psychospiritual goal for the session. Use this only as a collaborative formulation. [source: Krupitsky & Grinenko; Kolp et al., 2014]
  • Example language (illustrative): "If things get strange or uncomfortable, you don't need to fight it or fix it. You can notice it, breathe, and let me know with a hand signal if you need me."
  • Watch for: fixed outcome demands ("I must see my trauma"); fear the client has not voiced; the alliance not yet solid. If trust is thin, add preparation sessions. [synthesis]

4.4 Touch and boundaries agreement

  • Purpose: prevent boundary violations at a time of high suggestibility. [source: Journey Clinical/APA slides; Dames et al.]
  • Steps:
    1. Explain what supportive touch would be (Roots To Thrive shows a video on supportive touch) and that it is always optional. [source: Dames et al.]
    2. Discuss touch preferences and boundaries privately (Roots To Thrive does this in the physician consultation). [source: Dames et al.]
    3. Record the client's choices on a consent form. On the day, reconfirm them and make them visible to staff (Roots To Thrive uses a whiteboard). [source: Dames et al.]
    4. Never extend touch beyond what was agreed in the ordinary state. Treat any "yes" given during the altered state as not valid for expanding touch. [synthesis]
  • Example language (illustrative): "Some people like a hand on the shoulder if they get scared; others want no touch at all. Both are fine. Whatever you choose today is what we'll do on the day, and you can always reduce it."
  • Watch for: ambivalence, a trauma history around touch, and erotic or dependent transference. Work in two-person teams. [source: Dore et al.; Journey Clinical/APA slides] [synthesis for the specifics]

4.5 Setting design (the "nest")

  • Purpose: physical and relational safety. [source: Dore et al.; Dames et al.; Journey Clinical/APA slides]
  • Steps:
    1. Prepare a quiet, warm, low-stimulus room with a reclining chair or mat, blankets and cushions, dim lighting, an eye mask and headphones. Roots To Thrive also uses weighted blankets and affirmation cards. [source: Dames et al.]
    2. Prepare a playlist. Roots To Thrive calls music a "co-therapist throughout the journey". KPT played music throughout. [source: Dames et al.; Krupitsky & Grinenko]
    3. Attend to scent, sound and comfort items. Sessions may take place in the office, the client's home or a retreat space, as the medical plan permits. [source: Journey Clinical/APA slides]
    4. Show the client the room in advance (Roots To Thrive orients participants with photos, video and the playlist). [source: Dames et al.]
  • Example language (illustrative): "This is where you'll be. You can adjust the blanket and the light, and the music is there to carry you, not to tell you what to feel."
  • Watch for: noise or interruptions, music the client dislikes, and cultural mismatch in the décor or music. [synthesis]

4.6 First medicine session as calibration (therapist's part)

  • Purpose: in the Dore model, the first in-office session establishes each person's individual response and which state is reliably reached. The prescriber makes all medication decisions. [source: Dore et al.]
  • Steps (therapist role):
    1. Be present with the medical clinician as a dyad.
    2. Observe and note the client's state: able to talk and reflect (trance), or deeply inward or out-of-body (transformation). Note whether an observing self is still present. Share these observations with the prescriber. [source: Dore et al.]
    3. Afterwards, review with the client which state felt workable. [synthesis]
  • Example language (illustrative): "Today is partly about learning how this medicine works for you. There's no right experience to have."
  • Watch for: nausea or agitation (reported in a small percentage; medical staff manage them), and fear about losing control. [source: Dore et al.]

4.7 Accompaniment during the medicine session: interactive ("trance") mode

  • Purpose: use the lighter trance state for dialogue and "meditative self-reflection", the psycholytic-style use described by Dore et al. [source: Dore et al.; Mathai et al., 2022]
  • Steps:
    1. Sit close and stay steady. Keep a dyad present where possible. [source: Dore et al.]
    2. Invite the client to describe what is happening, using short, open, low-demand prompts. [synthesis]
    3. Follow the client's material rather than leading it, in line with the principle of supporting the person to find their own path. [source: Dore et al.]
    4. Offer reflections sparingly. Avoid interpretations, suggestions about memories, and value statements: suggestibility is heightened. [source: Journey Clinical/APA slides] [operationalisation: synthesis]
    5. If the client goes deeply inward, stop talking and hold space. [synthesis]
  • Example language (illustrative): "What's here now?" / "Stay with that a moment." / "You don't need to explain it."
  • Watch for: pressured talking that avoids feeling, distress, and loss of the observing self. It is working when the client can both feel and reflect, and produces their own meanings. [synthesis]

4.8 Accompaniment during the medicine session: inward ("in and down") mode

  • Purpose: support a contemplative, inward experience, as in the Roots To Thrive group sessions and Dore's deeper "transformation" state. [source: Dames et al.; Dore et al.]
  • Steps:
    1. Facilitators are already present and settled before participants arrive, and model inward focus. [source: Dames et al.]
    2. Use an eye mask and headphones with individually played music. Keep verbal communication to a minimum. [source: Dames et al.]
    3. Frame the opening with intention. Roots To Thrive frames the medicine as "an ally in healing" and uses a scripted, not read-verbatim, opening. [source: Dames et al.]
    4. Use ceremonial elements only where they are culturally sanctioned. Roots To Thrive includes elements drawn from Indigenous teachings shared with permission, for example burning used tissues afterwards, with Elders or cultural guides where appropriate. Do not import ceremony without that permission and authority; a clinician supports and respects, and does not run ceremony. [source: Dames et al.]
    5. Use touch only as pre-agreed (4.4). Tend to physical comfort (blanket, tissues) quietly. [source: Dames et al.]
  • Example language (illustrative, used before eyeshades go on): "I'll be right here. You don't need to talk. If you need anything, raise your hand."
  • Watch for: signs of distress under the mask. Check in briefly and non-verbally first. Medical signs belong to the medical team. [synthesis]

4.9 Post-peak psychotherapy and "initial sharing"

  • Purpose: begin processing while the experience is fresh. Dore et al. describe psychotherapy continuing as peak effects subside; KPT patients described their experience and interpretation began. Dames et al. use "initial sharing". [source: Dore et al.; Krupitsky & Grinenko; Mathai et al., 2022]
  • Steps:
    1. Let the client re-orient at their own pace, sitting up only when ready. [synthesis]
    2. Ask for a free account first. Defer interpretation. [synthesis]
    3. Note key images, words and feelings for later integration. [synthesis]
    4. Discharge only when medical staff confirm. In Roots To Thrive participants stay until steady, are escorted to a designated driver, follow a no-driving policy, and receive a written safety sheet with aftercare contacts. [source: Dames et al.; FDA label]
  • Example language (illustrative): "Take your time coming back. When you're ready, tell me whatever stands out, in any order."
  • Watch for: confusion, lingering dissociation, and wanting to make big decisions immediately. Suggest the client waits before acting on major decisions. [synthesis]

4.10 Written self-report the same day

  • Purpose: capture the experience before it fades. KPT patients wrote a detailed self-report the evening of the session, and Kolp et al. (2014) keep this step; Roots To Thrive uses journaling. [source: Krupitsky & Grinenko; Kolp et al., 2014; Dames et al.]
  • Steps:
    1. Give a simple prompt: what happened, what was felt, what seemed important. [synthesis]
    2. Ask the client to bring the writing (or drawings) to integration. [synthesis]
  • Example language (illustrative): "Tonight, if you can, jot down anything you remember. Even fragments are useful."
  • Watch for: writing becoming self-critical; adjust the prompt. [synthesis]

4.11 Integration: anchoring insights

  • Purpose: turn experience into lasting change. Dore et al. describe patients "anchoring" insights as "slogans, mantras, visions, internal movies" carried into daily life over several sessions. [source: Dore et al.; Journey Clinical/APA slides]
  • Steps:
    1. Review the self-report together. Ask which moments felt most meaningful. [synthesis]
    2. Help the client distil one or more anchors in their own words: a phrase, an image, a felt sense. [source: Dore et al.; wording synthesis]
    3. Link the anchor to the intention and to current problems. KPT linked symbolic experiences to personal problems and to the commitment to sobriety. [source: Krupitsky & Grinenko]
    4. Plan concrete behaviour (a conversation, a habit change, a practice) and review it at the next session. [synthesis]
  • Example language (illustrative): "If that image could become a sentence you'd want to remember on a hard Tuesday, what would it say?"
  • Watch for: spiritual bypassing, grandiosity, or insights that stay abstract. It is working when anchors are used between sessions and measures improve. [synthesis; measures: Dore et al.]

4.12 Group integration ("being" and "doing")

  • Purpose: shared meaning-making in familiar small groups and in mixed integration meetings after each medicine session. [source: Dames et al.; Krupitsky & Grinenko]
  • Steps:
    1. Open with a check-in of one to two sensations and one to two emotions. [source: Dames et al.]
    2. Invite sharing under the group's agreements. Others respond with compassionate witnessing, not advice. [source: Dames et al.]
    3. Explore the contrast between "being" (what was experienced) and "doing" (how to live it). [source: Dames et al.]
    4. Offer individual support or local referrals when needed. [source: Dames et al.]
    5. KPT held group sessions both the day before and the day after the medicine session and judged shared experience more powerful; Kolp et al. (2014) likewise recommend integration mainly in groups, with individual work as an option. Mark the KPT schedule as historical design. [source: Krupitsky & Grinenko; Kolp et al., 2014]
  • Example language (illustrative): "Let's hear what each person is carrying from that session, then we'll explore what it might ask of you this week."
  • Watch for: comparison ("mine wasn't as deep") and over-sharing. Normalise varied experiences. [synthesis]

4.13 Weekly community-of-practice sessions (Roots To Thrive)

  • Purpose: the main therapeutic container, moving from "knowing to being to doing". [source: Dames et al.]
  • Steps:
    1. Large group: a grounding invitation (often from an Elder or a reading), a somatic regulation practice, and a closing "pause" practice. [source: Dames et al.]
    2. Small group: intentions and agreements, the sensations-and-emotions check-in and check-out, open-ended prompts on the week's theme, and compassionate witnessing. [source: Dames et al.]
    3. Follow the 12-theme curriculum. It runs from foundations and body-based presence, through listening, emotional regulation and attachment, to self-compassion, community and purpose ("Locating Your North Star"). [source: Dames et al.]
    4. Use the named practices: mindful listening, RAIN, somatic regulation, journaling and self-reflection, plus optional EFT workshops. [source: Dames et al.]
  • Example language (illustrative): "Let's land: notice your feet, your breath, and one thing you can hear."
  • Watch for: members who cannot co-regulate in a group. Offer individual support. [source: Dames et al.; response synthesis]

4.14 Structured psychotherapies in the post-session window

  • Purpose: in plasticity-oriented models, evidence-based therapy is delivered after acute effects to consolidate change. [source: Mathai et al., 2022]
  • Approaches combined with ketamine in published studies: CBT; ERP for OCD; mindfulness-based relapse prevention and motivational enhancement for substance use; MBCT and FAP; prolonged exposure for PTSD; TIMBER. [source: Mathai et al., 2022]
  • ACT plus esketamine: Mathai et al. propose preparatory counselling, with ACT targeting psychological flexibility delivered relationally around esketamine treatment. They present it as a proposed model, not an established one. [source: Mathai et al., 2022]
  • Steps:
    1. Choose the protocol for the diagnosis.
    2. Schedule sessions so they fall after medically confirmed recovery, never while the client is impaired.
    3. Deliver the protocol as normally manualised. [synthesis]
  • Example language (illustrative): "While things feel more open, let's practise the exposure step we planned."
  • Watch for: exposure work needs the usual consent, contraindications and safety steps. Do not do exposure while the client is impaired. [synthesis]

4.15 Supporting a prescriber-approved at-home component

  • Purpose: Dore et al. describe a supervised at-home component in which patients recreate at home the set and setting established in office sessions. [source: Dore et al.] The therapist's part is the psychological frame only: preparation, setting, the support person, the safety plan and integration. Prescribing, supply, monitoring and every other medical arrangement belong to the prescriber, and nothing about administration is described here. [scope: synthesis]
  • Steps (therapist role):
    1. Help the client recreate set and setting at home.
    2. Confirm that a support person or sitter and a safety plan are in place, as the prescriber requires.
    3. Hold integration sessions after home sessions.
    4. Report any concern about misuse to the prescriber. [synthesis, based on Dore et al.'s description]
  • Example language (illustrative): "Let's plan your home space the way we set up the office: what you'll need, who'll be there, and what you'll do if you feel unsafe."
  • Watch for: use outside the agreed plan, use for escape, and unsafe home conditions. The FDA label stresses screening for abuse, misuse and dependence. [source: FDA label; synthesis]

4.16 Measurement and session-quality ratings

  • Purpose: guide decisions. Dore et al. tracked symptom scales and session-experience measures, and found clinician ratings correlated with self-report. [source: Dore et al.]
  • Steps:
    1. Repeat the symptom measures at agreed intervals.
    2. After each session, rate session quality and state reached, using the team's licensed instruments.
    3. Review trends with the prescriber. [source: Dore et al.; steps synthesis]
  • Watch for: a high mystical-experience score with no life change, which calls for more integration work. [synthesis]

4.17 Maintenance, relapse prevention, discharge and alumni

  • Purpose: keep gains. [source: Dore et al.; Dames et al.]
  • Steps:
    1. Shift to less frequent or relapse-prevention-focused medicine sessions, as the prescriber decides. [source: Dore et al.]
    2. At discharge, repeat intake measures and send a summary to the referring provider. [source: Dames et al.]
    3. Offer alumni community-of-practice access, and refreshers when clinically indicated. [source: Dames et al.]
    4. Write an individual relapse-prevention plan built on the client's anchors. [synthesis]
  • Watch for: reliance on the medicine rather than the skills. [synthesis]

4.18 Family-and-friends groups

  • Purpose: support the client's network. Roots To Thrive offers family-and-friends groups at three points in the programme. [source: Dames et al.]
  • Steps:
    1. Explain the programme to supporters.
    2. Explain how to support integration and what warning signs to report. [synthesis]
  • Watch for: confidentiality preferences. [synthesis]

4.19 Harm reduction and integration for clients using outside services [synthesis]

  • Purpose: many clients obtain ketamine from clinics or online services with "minimal support or coverage", in Wolfson's criticism. [source: Duncan interview] The therapist's role here is assessment, education, safety planning, integration and referral. It is never to facilitate use.
  • Steps:
    1. Ask non-judgmentally where and how the client is receiving treatment, and whether a prescriber is monitoring them.
    2. Assess mental-state risk, substance use and bladder or cognitive symptoms (warning areas on the FDA label).
    3. Give general risk education: dependence, mixing with alcohol or sedatives, no driving, having someone present. Give no amounts.
    4. Offer integration sessions.
    5. Refer to a supervised medical programme where indicated.
  • Example language (illustrative): "I'm not here to judge. I want to help you make sense of what you're experiencing and keep you as safe as possible."
  • Watch for: escalating use and use to manage withdrawal or distress. Treat these as signs of possible use disorder and refer. [synthesis]

4.20 Historical element, not for use: KPT aversive pairing

  • What it was: in Krupitsky's KPT for alcoholism, alcohol cues such as the smell of alcohol were introduced at intense moments to build aversion. The therapist also gave directive verbal guidance tailored to the patient's history. [source: Krupitsky & Grinenko, 1997]
  • What happened next: later work shifted toward existential and transpersonal aims. [source: Mathai et al., 2022]
  • Status: directive suggestion and aversive conditioning during altered states conflict with current consent and boundary standards. Do not use them. If a client describes having had such treatment, explore its meaning and any distress in ordinary psychotherapy. [synthesis]

4.21 Death-rehearsal work for end-of-life anxiety (Kolp's ketamine-enhanced psychotherapy)

  • Purpose: for a terminally ill client with death anxiety who asks for it, a short, time-limited course of assessment, preparation, one accompanied medicine session and integration, framed as a psychological "death rehearsal" and a chance to revisit beliefs about dying. Kolp et al. (2007) describe it in two hospice case reports; it is preliminary, uncontrolled case material, and the authors call for controlled research. [source: Kolp et al., 2007]
  • Steps:
    1. Assessment session: decide with the client and the prescriber whether the approach fits. The case reports give no detailed screening criteria, so the medical and psychiatric screen in 4.1 applies, coordinated with the hospice team. [source: Kolp et al., 2007; screening: synthesis]
    2. Preparation sessions (the case reports used two, weekly; one took place in the client's home): build the alliance; explore the client's beliefs about an afterlife and attitudes towards death; build an individual "psychotherapeutic myth" together; agree a psychospiritual goal for the session; say that the session may bring insights about these beliefs, without promising any. [source: Kolp et al., 2007]
    3. Leave every question about the client's other medicines to the prescriber; the therapist can raise it but does not advise. [scope]
    4. Session: invite the client to surrender to the experience, with specially chosen, non-intrusive music; the therapist attentively supervises alongside the medical team. [source: Kolp et al., 2007; Kolp et al., 2014]
    5. Integration: with the client, discuss and interpret the personal significance of the symbolic content (in the case reports this included a life review, guilt and changed images of the divine), and link it to how the client wants to meet the time that remains. [source: Kolp et al., 2007; link to remaining time: synthesis]
    6. Respect a decision not to continue, and keep offering ordinary palliative psychological support whatever the outcome. [synthesis]
  • Example language (illustrative): "We've talked about what you believe happens when we die. Whatever comes up in the session, we'll look at it together afterwards, at your pace."
  • Watch for: an experience of dissolution and fear that leaves the anxiety unresolved, as happened in one of the two cases; Kolp et al. stress that the ketamine experience brings no benefit by itself without the relationship, preparation, supervision and integration, and suggest that clients with much prior psychedelic use may gain less. Time is short in palliative care: plan integration early. [source: Kolp et al., 2007]

5. Handling problems

The sources say little about handling problems in psychotherapy terms. Most of what follows is [synthesis] built on the sources' safety statements. Every medical sign or symptom goes to the medical team.

  • Fear, panic or a frightening experience during a session. KPT patients reported "fear and even horror". Anxiety during treatment has been linked to poorer antidepressant response. [source: Krupitsky & Grinenko; Mathai et al., 2022] Response: use calm, brief, non-verbal reassurance first. Then offer an orienting phrase and reminders agreed in preparation ("you are safe, this will pass"). Use touch only if pre-agreed. Alert medical staff, who decide on any medical response (Roots To Thrive keeps physician-guided comfort medication available). Afterwards, process the experience as meaningful rather than as failure. [synthesis; Dames et al. for medical availability]
  • Overwhelm or trauma flooding in integration. Response:
    • Slow down and return to somatic regulation and grounding (as in the Roots To Thrive practices).
    • Shift from content to stabilisation.
    • Consider pausing medicine sessions until the client is stable. [synthesis; practices: Dames et al.]
  • Rigid or controlled clients who resist the state. Dore et al. note that rigid personality structures may find the trance difficult. Response:
    • Spend more preparation time on what letting go means, without pressure.
    • Accept partial experiences.
    • Discuss with the prescriber whether KAP fits. [source: Dore et al.; response synthesis]
  • Non-response. Dore et al. report that a small minority do not respond and that ketamine "is not for everyone". Response:
    • Review measures, adherence to integration, and life stressors with the prescriber.
    • Do not escalate on the client's demand.
    • Offer other treatments without blame. [source: Dore et al.; synthesis]
  • Nausea, vomiting, agitation. Dore et al. report these in a small percentage, rarely leading to stopping. Response: medical staff manage them. The therapist normalises and keeps the setting calm. [source: Dore et al.]
  • Physical warning signs. Chest pain, shortness of breath, severe headache, vision change, seizure, marked sedation or breathing problems: these are medical emergencies for the medical team. Know the emergency protocol, which Roots To Thrive clinicians review before every session. At least one person on site must hold first-aid and basic life support training. [source: FDA label; Dames et al.]
  • Misuse, craving, dependence. The FDA label warns of physical and psychological dependence and asks for screening before and during treatment. Response:
    • Ask directly at every session about use outside the plan.
    • Watch for requests for more sessions to escape distress.
    • Coordinate with the prescriber.
    • Use motivational work and a substance use assessment. [source: FDA label; synthesis]
  • Bladder or cognitive symptoms. The label asks patients to report urinary urgency, frequency or pain, and problems with thinking or memory. Response: ask routinely and pass reports to the prescriber. [source: FDA label]
  • Suicidality. The label warns of increased suicidal thoughts in people 24 and younger on antidepressants, and esketamine is not a substitute for hospitalisation. Response:
    • Use standard structured risk assessment at intake and throughout.
    • Keep a collaborative safety plan, with lethal-means counselling (safe storage or removal) as standard.
    • Use the usual crisis pathway; never rely on the medicine session as crisis care. [source: FDA label; response synthesis]
  • Non-adherence to preparation or integration. Roots To Thrive requires preparation to be completed and weekly sessions attended. Response:
    • Explore barriers.
    • Make the link explicit: no integration means no next medicine session, by agreement with the prescriber. [source: Dames et al.; synthesis]
  • Ruptures, idealisation and erotic or dependent transference. Suggestibility and vulnerability are heightened. Response:
    • Name it gently and keep boundaries, including the "not needing" stance.
    • Bring it to supervision.
    • Never alter touch or contact rules mid-treatment.
    • Repair openly in line with relational accountability. [source: Journey Clinical/APA slides; Dore et al.; Dames et al.; synthesis]
  • Therapist suggestion and false-memory risk. Response: no leading questions about abuse or memories during or right after sessions. Treat images as experiences to explore, not as historical facts. [synthesis, grounded in the suggestibility warning]
  • Grandiosity, spiritual bypassing, impulsive life decisions. Response:
    • Reality-test gently.
    • Advise waiting before major decisions.
    • Ground insights in behaviour. [synthesis] Bring Wolfson's caution that the experience must be "contextualized" or it can be used "very negatively". [source: Duncan interview]
  • Lingering dissociation or derealisation. Response:
    • Give grounding practices.
    • Review medical causes with the prescriber.
    • Pause sessions if it persists. [synthesis]
  • Group problems (comparison, dominance, contagion of distress). Response:
    • Re-state the agreements.
    • Use the dyad: one facilitator holds the group while the other attends to the individual.
    • Use individual follow-up. [Dames et al. for dyads and individual support; rest synthesis]
  • Cultural and spiritual material. Response: attribute spiritual interpretations to the client's own framework. Do not import ceremony. Invite cultural guides only where communities have shared teachings with permission (as Roots To Thrive describes). [source: Dames et al.; synthesis]
  • Clients from online or commercial services with little support. See 4.19. Wolfson describes this market as "out of control". [source: Duncan interview]
  • Scope creep for the therapist. Never advise on amounts, timing or obtaining ketamine. Keep KAP within your competence and get additional training and supervision. [source: Journey Clinical/APA slides]
  • Historical claims. Some clients or colleagues cite KPT-style success rates or aversive methods. Response: explain that these came from uncontrolled, developer-reported data (1997 review) and that aversive and directive suggestion techniques are not current practice. [source: Krupitsky & Grinenko; synthesis]

Not found or uncertain.

  • Kolp's practical guidance: the technique from the 2014 guide and the 2007 case reports is included (2, 4.3, 4.10, 4.12, 4.21). Kolp's account of his own later practice and the guide's full practical-advice material are not summarised here. Both sources are preliminary, uncontrolled clinical writing. [uncertain]
  • Roots To Thrive's inclusion and exclusion criteria and contraindications are set out in Supplementary File 6 (the "KaT Medical Protocol") of Dames et al., 2025; the main text defers to that file and lists none, and its contents are not reproduced here. The main text does state referral by a licensed provider, a readiness checklist, completion of all preparation, and referral for further psychological assessment when indicated. A 2023 chart-review abstract (Tsang et al.) lists the conditions treated (PTSD, depression, generalised anxiety, burnout or adjustment disorder, substance use disorder, OCD, disordered eating and disordered sleep) but gives no exclusions. Follow your own programme's medical protocol. [uncertain]
  • Outside the US: Canada (ketamine prescribing) and Australia (esketamine) verified; UK verified only for NICE's 2020 draft decision; EU only from a secondary report. Off-label ketamine rules in the UK, EU and Australia, MHRA licensing and Health Canada's esketamine decision were not verified. [uncertain]
  • No training material from the Ketamine Research Foundation is used here. [uncertain]

Sources

Main sources:

Further sources:

Books cited:

  • Wolfson, P., & Hartelius, G. (Eds.) (2016). The Ketamine Papers: Science, Therapy, and Transformation. MAPS.
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