Psycholytic versus psychedelic-style ketamine sessions

1. Introduction

Version followed: the "experience-oriented" typology of Mathai, Mora & Garcia-Romeu (2022), which splits ketamine–psychotherapy into a psycholytic style (lower-intensity sessions, therapy conducted relationally during the acute effects) and a psychedelic style (higher-intensity, inward-directed sessions bracketed by preparation and integration). For the psychedelic-style procedure this guide follows Krupitsky's Ketamine Psychedelic Therapy (KPT; Krupitsky & Grinenko 1997 review; Krupitsky et al. 2001/2002 heroin trial). For the graded, interactive (psycholytic-like) procedure it follows the "trance" vs "transformation" model of Dore, Wolfson and colleagues (2019). [source: Mathai et al. 2022; Krupitsky & Grinenko; Krupitsky et al. 2001; Dore et al. 2019]

What it is. This entry is a classification of session styles, not a single branded therapy. The terms come from mid-20th-century LSD therapy, where "psycholytic" meant repeated lower-intensity sessions used to loosen defences inside an ongoing psychotherapy and "psychedelic" meant a few high-intensity sessions aimed at a peak or transcendent experience [uncertain: the historical derivation is standard in the field but was not confirmed in a source opened for this guide; Mathai et al. use the terms without tracing their origin]. Applied to ketamine:

Psycholytic-style: the drug is used to "facilitate the therapeutic and relational quality of ongoing psychotherapy" (Mathai et al. 2022); the client stays in conversational contact and the altered state is treated as material for the therapy. Dore et al. (2019) call this the trance state: awareness and communication with the therapist are preserved, usually with less speech.
Psychedelic-style: the aim is a profound, peak or mystical-type experience that is "inner-directed, rather than primarily relational" (Mathai et al. 2022), followed by integration. Dore et al. call this the transformational state (ego-reductive, out-of-body quality, little verbal report). Krupitsky's KPT is the prototype.
A third, contrasting family, plasticity-oriented ketamine plus psychotherapy (CBT, exposure, mindfulness-based relapse prevention, motivational enhancement delivered outside the acute effects), gives the drug experience little weight. It is mentioned here only for contrast (see 4.17). [source: Mathai et al. 2022; Drozdz et al. 2022]

Core idea of change. In both experience-oriented styles the altered state is therapeutic material, not a side effect; Dore et al. describe psychedelic effects as "an integral part of KAP". In the psycholytic style change comes through ordinary psychotherapeutic processes (insight, approaching feared material with less fear, a strengthened relationship) made easier by the trance. In the psychedelic style change is attributed to a vivid symbolic or transpersonal experience (ego dissolution, death-rebirth themes, a sense of unity) that shifts self-concept, values and meaning in life, which integration then links to the presenting problem. Krupitsky's group framed this in Frankl's terms: addiction as an "existential void". [source: Dore et al. 2019; Krupitsky & Grinenko; Krupitsky et al. 2001]

Scope and safety rule for this guide. This guide covers the psychotherapy and safety frame only. It gives no doses, dose ranges, routes, schedules or drug combinations. All decisions about the drug, and all medical monitoring, belong to the prescribing and medical staff.

Legal and regulatory status (as of the sources' dates).

United States: ketamine is FDA-approved only as an anaesthetic and is a controlled substance; psychiatric use of racemic ketamine is off-label. Esketamine (Spravato) is approved for treatment-resistant depression and for depressive symptoms with acute suicidal ideation or behaviour, alongside an antidepressant, under a REMS that restricts dispensing and administration to certified, medically supervised settings with post-administration monitoring for sedation, dissociation and misuse. In October 2023 the FDA warned about compounded ketamine products, particularly at-home use without monitoring, and named risks including abuse and misuse, psychiatric events, raised blood pressure, slowed breathing and bladder/urinary-tract symptoms. [source: HealthDay report of the FDA warning, Oct 2023] Ketamine's US federal schedule is commonly given as Schedule III [uncertain].
United Kingdom: esketamine holds a marketing authorisation for treatment-resistant depression but NICE did not recommend it for NHS use (uncertain long-term benefit, comparator evidence and cost). [source: European Pharmaceutical Review] Ketamine's UK controlled-drug class is [uncertain].
Russia: Krupitsky's research was interrupted by changes to Russian ketamine regulations around 2001 and later rescheduling over recreational-use concerns. [source: Krupitsky MAPS update; Mathai et al. 2022]
Other jurisdictions: not researched for this entry [uncertain]. Check local law and professional-body guidance before any involvement.

2. Framework

Both styles share one arc: assessment and screening → preparation → ketamine session(s) → post-session recovery → integration → follow-up. They differ mainly in what happens inside the session and in how sessions relate to the wider therapy. [source: Krupitsky et al. 2001; Dore et al. 2019; Mathai et al. 2022]

2.1 Psychedelic-style (KPT model)

Phase	Goals	Format and length (as published)
Screening	Diagnosis, motivation, medical and psychiatric suitability	In KPT: detoxified in-patients who had finished a hospital phase (alcohol) or acute detoxification (heroin)
Preparation	Build trust; explore motives, goals for a drug-free life, beliefs about the illness; prepare for unusual experiences; co-create the individual "psychotherapeutic myth"	Up to about 10 hours of individual psychotherapy (heroin trial)
Session	Profound experience guided toward symbolic resolution of conflicts and a final cathartic peak	One session per patient in the 2002 trial; reclining, eyeshades, music; psychotherapist plus a separate medical doctor (anaesthesiologist) present throughout
Recovery	Rest; first verbal processing; detailed written self-report the same evening	Supervised
Integration	Interpret the symbolism; connect it to the drug problem; strengthen commitment to a drug-free life	Up to about 5 hours of individual therapy (heroin trial); group meetings the day before and day after the session (alcohol programme)
Follow-up	Relapse monitoring and support	Monthly, up to 24 months, in the trial

[source: Krupitsky et al. 2001; Krupitsky & Grinenko] A later Krupitsky trial compared a single session with repeated sessions, because nearly half the high-intensity group relapsed within three months. [source: Krupitsky MAPS update; Krupitsky et al. 2001]

2.2 Psycholytic-style / graded "trance to transformation" model (Dore, Wolfson et al.)

Intake: full psychiatric evaluation, medical, psychiatric, substance and family history; clinician ratings that include personality rigidity and concerns.
First ketamine session: used to learn the person's individual response, so that the prescriber can find a range that reliably produces the trance state. Sensitivity is idiosyncratic and is learned from experience, not predicted.
Trance-mode work: ketamine sessions embedded in continuing psychotherapy, with psychotherapy also between sessions. Sessions are long and are followed by supervised recovery. Two clinicians attend, or a second therapist is on the premises.
Optional transformational-mode sessions: moving on is at the provider's discretion, based on therapeutic progress and symptom relief. Not all clients move to it.
Integration throughout, by "anchoring" what was gained. [source: Dore et al. 2019]
No standard number of sessions is published. [source: Dore et al. 2019; Drozdz et al. 2022]

2.3 Criteria for choosing a style and moving between phases

No published decision rule exists. Mathai et al. recommend that clinical expertise, together with "patient characteristics, culture and preferences", guide the choice. Early Iranian work linked personality dimensions to the kind of ketamine experience people had. [source: Mathai et al. 2022]
Toward psycholytic/trance work first [synthesis]: goals that are relational or narrative (trauma processing, shame, grief, attachment themes) where staying in contact helps; clients frightened of losing control; first exposure to ketamine; a therapy already under way that the session should serve.
Toward psychedelic-style work [synthesis, informed by KPT and Dore]: existential or meaning-centred goals, addiction where a values or identity shift is the target, and clients who have tolerated trance sessions well and whose progress has stalled. Dore et al. leave this step to the provider's judgement based on progress and symptom relief.
Screening to preparation: medical and psychiatric clearance documented by medical staff; consent signed. [source: Field Trip Health effectiveness preprint; Dore et al. 2019]
Preparation to session [synthesis drawing on KPT]: trust is established; the client can describe what may happen (bodily separation, ego dissolution, frightening imagery) and how the team will respond; a shared intention or "myth" is written down; signals and touch agreements are settled; transport home is arranged.
Session to integration: the client is oriented, medically cleared by staff and has written or recorded the experience. [source: Krupitsky et al. 2001; synthesis]
Integration to next session or ending [synthesis]: insights are anchored in concrete behaviour; no unresolved destabilisation; progress is reviewed with the prescriber before any further session.

3. Guiding principles

Set and setting are active ingredients. In Krupitsky's trial the lower-intensity group also found sessions meaningful, and the authors attributed part of that response to set and setting. Practice: invest as much care in preparation, room and relationship as in the medical side. [source: Krupitsky et al. 2001; Mathai et al. 2022]
The experience is material, not a side effect. Practice: do not try to suppress or skip the altered state; plan how it will be worked with. [source: Dore et al. 2019; Mathai et al. 2022]
Match the therapist's stance to the style. Psycholytic work is relational and interactive; psychedelic work is inner-directed. Practice: in trance sessions keep up gentle dialogue; in psychedelic sessions speak little and mainly support. [source: Mathai et al. 2022; synthesis]
Trust is the central task of preparation. Practice: do not schedule a ketamine session until the client feels known and safe with you. [source: Krupitsky et al. 2001]
Individual tailoring through a shared narrative. KPT's individually built "psychotherapeutic myth" was regarded by its authors as the key therapeutic factor for session content. Practice: co-author, with the client, a short account of why they are doing this and what the problem means. [source: Krupitsky et al. 2001; Krupitsky & Grinenko]
Existential and meaning orientation. Practice: ask about values, purpose and what a life without the symptom or drug would be for, not only about symptoms. [source: Krupitsky et al. 2001]
A place of safety and warmth. Dore et al. use Winnicott's image of a "nest". Practice: a comfortable, private, unhurried room with predictable staff. [source: Dore et al. 2019]
A more human posture with firm boundaries. Dore et al. describe a more intimate and disclosing therapist posture while keeping the boundary of "not needing" the patient. Practice: warmth and some self-disclosure, never meeting your own needs through the client. [source: Dore et al. 2019]
"An altered state is a vulnerable state." Practice: two clinicians in the room, or a second clinician on the premises; no solo sessions. [source: Dore et al. 2019; Krupitsky et al. 2001]
Separate the therapeutic and medical roles. KPT had a psychotherapist plus an anaesthesiologist; Field Trip Health had medical staff monitoring vital signs. Practice: the therapist never manages medical monitoring or the drug. [source: Krupitsky et al. 2001; Field Trip preprint]
Do not impose values; keep the observing self active. Practice: invite the client's own meaning-making and help them keep a witnessing stance during the session. [source: Dore et al. 2019]
Integration is core, not optional. Practice: book integration sessions before the ketamine session. [source: Dore et al. 2019; Krupitsky et al. 2001; Drozdz et al. 2022]
Response is individual. Practice: expect the same session style to feel very different across clients; review each session with the prescriber. [source: Dore et al. 2019]
Regulated, supervised settings only. Practice: work only within legal, medically supervised programmes; for unsupervised or illicit use offer harm reduction and integration, never facilitation. [source: FDA warning via HealthDay; synthesis]
Difficult content may matter but is never forced. In KPT, patients with more negative experiences had longer remissions. Practice: help clients stay with hard material if they can, without steering them into it. [source: Krupitsky & Grinenko; synthesis]

4. Intervention inventory

The sources publish a frame and a session structure rather than a scripted technique list. Items below follow that structure. Steps that go beyond what the sources state are marked [synthesis]. All example language is illustrative unless quoted.

4.1 Psychiatric and medical screening (shared with medical staff)

Purpose / when: before any preparation work; decides eligibility and which style is suitable.
Steps:
1. Confirm that a psychiatrist or psychiatric nurse practitioner has completed a full assessment: diagnosis, medical, psychiatric, substance-use and family history. [source: Dore et al. 2019; Field Trip preprint]
2. Check the exclusions one published programme used: pregnancy or breastfeeding (postpartum depression case-by-case); psychosis; active mania; borderline personality disorder; recent substance use disorder without reduced use; uncontrolled medical conditions; recent acute brain injury; moderate-to-severe sleep apnoea; raised BMI as a relative contraindication; no safe way home. Other programmes set different criteria, so use your own programme's list. [source: Field Trip preprint]
3. Add the therapist's view on personality rigidity. Dore et al. found that people with very rigid structures (severe OCD, personality disorders, possibly severe PTSD) may find the trance state hard to enter and to benefit from. [source: Dore et al. 2019]
4. Screen for personal or family history of psychosis or bipolar disorder, current suicidality (standard structured risk assessment), past problematic ketamine or other dissociative use, and bladder or urinary symptoms to pass to the medical team. [synthesis, consistent with FDA-named risks]
5. Record a provisional style recommendation (trance/psycholytic first vs psychedelic-style) and its rationale. [synthesis]
Example language (illustrative): "Before we talk about the experience itself, the medical team and I need a full picture of your health, including things that might make ketamine a poor fit for you."
Watch for: minimising past substance use; pressure to proceed quickly; family history disclosed late. Working when: eligibility is documented by medical staff and both of you understand the reasons for the chosen style.

4.2 Informed consent and expectation-setting

Purpose / when: after screening and before preparation; revisit before every session and before any change of style.
Steps:
1. Explain the regulatory position: approved esketamine within REMS, or off-label racemic ketamine, and what that means. [source: FDA warning via HealthDay]
2. Explain both styles and which one is planned, and that moving from trance to transformational sessions is a later, separate decision. [source: Dore et al. 2019]
3. Describe common acute and short-term effects in plain terms (nausea, vomiting, agitation, dizziness, derealisation, drowsiness) and that a small group cannot tolerate the nausea or do not respond. [source: Dore et al. 2019]
4. Describe the team: who is present, who is responsible for medical monitoring, and the recovery period before leaving. [source: Krupitsky et al. 2001; Field Trip preprint]
5. Agree on touch, in writing: whether any supportive touch is acceptable, what kind, and how the client can withdraw consent during the session. [uncertain: none of the sources sets out a touch policy; this step is synthesis following general psychedelic-therapy practice]
6. Obtain written consent. [source: Dore et al. 2019; Krupitsky & Grinenko; Field Trip preprint]
Example language (illustrative): "In the gentler sessions you will usually be able to talk with me. In a deeper session you may lose track of your body and of the room for a while. Both are expected, and someone from the team will be with you the whole time."
Watch for: consent driven by desperation or by the hope of a "cure" in one session. Working when: the client can explain the plan, the risks and the opt-outs in their own words.

4.3 Preparation interview: motives, goals and illness beliefs

Purpose / when: the first preparation sessions in both styles. In KPT this was up to about 10 hours of individual psychotherapy.
Steps [source: Krupitsky et al. 2001; Krupitsky & Grinenko]:
1. Explore why the client wants treatment now and what they expect from it.
2. Explore their goals for life after recovery (in KPT, a drug-free life) and what those goals are for.
3. Elicit their beliefs about the causes and consequences of the problem.
4. Explore meaning in life and values, in line with KPT's existential orientation.
5. Throughout, make building trust and mutual understanding the explicit priority.
Example language (illustrative): "If this treatment worked, what would you be doing differently a year from now, and why would that matter to you?"
Watch for: purely symptom-focused goals with no picture of the life wanted; low trust (guardedness, testing). Working when: the client talks about values and meaning, not only symptom relief.

4.4 Co-constructing the "psychotherapeutic myth" (individual intention narrative)

Purpose / when: late preparation, mainly in psychedelic-style work. KPT treated the individually tailored myth as the key factor for session content. [source: Krupitsky et al. 2001]
Steps:
1. From the preparation dialogue, draft with the client a short narrative of the problem as a symptom of deeper personal conflicts, which is how KPT framed alcoholism. [source: Krupitsky & Grinenko]
2. Include what the session is hoped to offer: insight into the harm the problem does and the value of life without it. [source: Krupitsky et al. 2001]
3. Keep it in the client's words and check it against their own beliefs (see 4.3). [synthesis]
4. Write it down; reread it together just before the session and again at integration. [synthesis]
Example language (illustrative): "So the story we have arrived at is that drinking filled a place where meaning used to be, and the session is a chance to look at that place directly. Does that fit for you?"
Watch for: a narrative imposed by the therapist (it conflicts with Dore's principle of not imposing values). Working when: the client corrects and owns the narrative.

4.5 Preparing for unusual experiences

Purpose / when: before the first session of either style; in more depth before psychedelic-style sessions.
Steps [source: Krupitsky et al. 2001; Krupitsky & Grinenko]:
1. Describe phenomena the sources report: a sense of separating from the body, dissolution of the ego, tunnels or corridors, death-and-rebirth themes, apocalyptic fear, loneliness, oceanic unity. Experiences can mix awe with horror and are often hard to put into words.
2. Explain that content is usually personal (life history, family, the problem itself) despite these common themes.
3. Encourage an attitude of surrender to the experience rather than fighting it (KPT).
4. Rehearse what the client can do if frightened: breathe, notice the music, remember that the team is present, use the agreed signal. [synthesis]
5. For clients with existential or spiritual frameworks, explain that near-death-like or transcendent experiences can occur and will be explored on the client's own terms. [synthesis; Kolp's view that such experiences may speed psycho-spiritual growth is reported via Sienknecht 2020]
Example language (illustrative): "Some people feel they have left their body or that 'they' have dissolved. If that happens, you don't need to hold on. Let it move through, and know we are right here."
Watch for: catastrophic interpretations ("I will go mad"; "I will die"); a dissociative trauma history that makes depersonalisation feel dangerous. Working when: the client can describe these possibilities calmly and knows the plan for responding to them.

4.6 Choosing and agreeing the session style

Purpose / when: end of preparation, and again after each session.
Steps:
1. Review goals, personality factors and preferences (Mathai et al.).
2. Discuss the provisional style with the prescriber. Intensity decisions are theirs; the therapist contributes the psychological case. [source: Dore et al. 2019; scope rule]
3. If the graded model is used, explain that the first session is mainly for learning how the client responds. [source: Dore et al. 2019]
4. Agree what the therapist will do: talk with the client (trance) or stay mostly silent and supportive (psychedelic). [synthesis]
Note on typologies: a four-level typology of ketamine experience (empathogenic, out-of-body, near-death, ego-dissolving transcendental) is widely attributed to Kolp and colleagues and is used in some practices to describe intensity to clients [uncertain: the primary Kolp et al. 2014/2016 texts are not drawn on here; the secondary page describes the levels from patient accounts and does not cite Kolp]. Use it only as a description, not as a protocol.
Example language (illustrative): "Today we will start with the lighter, trance-like kind of session, so we can talk as things unfold. Whether we ever go deeper is something we will decide together, with the doctor, later on."
Watch for: a client pushing for the "deepest" experience as a goal in itself. Working when: the style follows the therapeutic goals.

4.7 Preparing the setting

Purpose / when: every session.
Steps:
1. A comfortable couch or reclining chair in a calm room designed for relaxation; aim for "a place of safety and warmth". [source: Krupitsky et al. 2001; Field Trip preprint; Dore et al. 2019]
2. Eyeshades available (standard in psychedelic-style sessions; optional in trance work, where eye contact may support dialogue [synthesis]). [source: Krupitsky et al. 2001; Field Trip preprint; Sienknecht 2020]
3. Pre-selected music. KPT used stereophonic music, typically by New Age composers, played throughout and used to help steer the experience. [source: Krupitsky et al. 2001]
4. Medical staff set up their monitoring; the therapist is not involved in it. [source: Field Trip preprint]
5. Reread the intention or myth together; confirm signals, touch agreement and transport home. [synthesis]
Example language (illustrative): "Let's read your intention once more. Then I'll start the music, and you can put on the eyeshades whenever you are ready."
Watch for: music the client finds intrusive; a room where interruptions are possible. Working when: the client settles and reports feeling safe.

4.8 Conducting a psycholytic-style (trance) session

Purpose / when: lower-intensity sessions that serve ongoing psychotherapy; the client can still communicate.
Steps (the sources describe the stance, not a step sequence; the order is [synthesis]):
1. Open with the agreed focus, for example a feared memory, a relationship or a depressive belief. Dore et al. describe the trance as easing obsessive and depressive preoccupation and helping people approach difficult states with less fear. [source: Dore et al. 2019]
2. Use brief, open, unhurried prompts; expect slower and sparser speech. [source: Dore et al. 2019; synthesis]
3. Help the client keep an observing stance: invite them to describe what they notice as well as feel it. [source: Dore et al. 2019]
4. Work relationally: reflect, validate, and allow more warmth and self-disclosure than usual while keeping boundaries. [source: Dore et al. 2019]
5. Reflect insights back in the client's own words so they can be anchored later (see 4.14). [synthesis]
6. Leave silences; do not fill every pause. [synthesis]
Example language (illustrative): "What is it like to think about him from here?" / "You said it feels further away now. Stay with that for a moment."
Watch for: deepening into a less communicative state (stop probing and switch to support); over-talking by the therapist; trauma flooding (see 5). Working when: the client can approach material they usually avoid, with less fear, and recalls the session afterwards.

4.9 Conducting a psychedelic-style session (KPT-type)

Purpose / when: higher-intensity, inward-directed sessions aimed at a peak or transformative experience.
Steps:
1. Client reclines with eyeshades and music. The psychotherapist and a medical doctor are present throughout. [source: Krupitsky et al. 2001]
2. Provide emotional support. KPT therapists also gave verbal psychotherapy during the experience, drawn from the patient's history and aimed at personality problems and a stable orientation toward the goal. [source: Krupitsky et al. 2001]
3. Use brief verbal guidance together with the music to steer toward symbolic resolution of conflicts and a final cathartic peak. Speech is sparse because verbal report is limited in this state. [source: Krupitsky et al. 2001; Dore et al. 2019]
4. In KPT, guidance was linked to the presenting problem (alcohol or heroin themes). [source: Krupitsky & Grinenko]
5. As the effects wane, help the client re-orient gently: voice, name, the room. [synthesis]
Note: KPT's verbal steering is directive. Many current practitioners intervene less in deep sessions, and Mathai et al. describe this style as inner-directed [synthesis/uncertain: the degree of guidance varies between programmes; state which you follow].
Example language (illustrative): "You're safe. Let the music carry you." / "Whatever you are meeting, you can turn toward it."
Watch for: physical distress, which goes to medical staff at once; panic (see 4.10). Working when: the client later reports a meaningful or symbolic experience that connects to their goals.

4.10 Supporting a difficult experience in session

Purpose / when: fear, horror, panic or distressing imagery during either style.
Steps:
1. Any physical warning sign (breathing, blood pressure, vomiting, agitation) is handed straight to medical staff. [source: Krupitsky & Grinenko; Dore et al. 2019; Field Trip preprint]
2. Offer calm, reassuring verbal contact and remind the client the team is present. [source: Krupitsky & Grinenko]
3. KPT therapists guided patients away from frightening imagery toward calmer scenes and reframed distress in terms of the presenting problem. [source: Krupitsky & Grinenko]
4. Alternatively, where the client prepared for it and is able, encourage them to stay with and turn toward the material while their observing self stays active. [source: Dore et al. 2019; synthesis]
5. Use touch only as agreed in advance (4.2). [synthesis]
6. Note the content for integration; difficult content is not a failure. [source: Krupitsky & Grinenko; synthesis]
Example language (illustrative): "This is the ketamine. It will pass. I'm right beside you." / "Can you let the picture change? Notice the music."
Watch for: escalating agitation or attempts to get up, which call for the medical team; signs of trauma re-experiencing. Working when: arousal settles and the client stays connected to your voice.

4.11 Post-session recovery and written self-report

Purpose / when: straight after every session.
Steps:
1. Supervised recovery until medical staff clear the client. [source: Dore et al. 2019; Krupitsky et al. 2001]
2. A brief first conversation once the client is able, which is listening rather than interpreting. [source: Krupitsky & Grinenko; synthesis]
3. Ask the client to write a detailed account of the experience that evening (KPT practice). [source: Krupitsky et al. 2001]
4. Confirm safe transport home and give an emergency contact. [source: Field Trip preprint exclusion "no safe way home"; synthesis]
Example language (illustrative): "No need to make sense of it yet. Tonight, write down everything you remember, even the parts that seem strange."
Watch for: lingering derealisation; distress on returning home. Working when: the client leaves oriented and has a record of the experience.

4.12 Group sharing before and after sessions (KPT alcohol programme)

Purpose / when: a group context for interpreting experiences, used in the KPT alcohol programme the day before and the day after sessions.
Steps [source: Krupitsky & Grinenko; detail is synthesis]:
1. The day before: members share their intentions and fears.
2. The day after: each describes their session; the group helps interpret the symbolism and link it to life and recovery goals.
3. The therapist keeps interpretation in the speaker's hands and stops members from imposing meanings. [synthesis]
Example language (illustrative): "What did that image mean to you? Others may have ideas, but yours comes first."
Watch for: comparing or ranking experiences; pressure to report something spiritual. Working when: members leave with personal links between the experience and their goals.

4.13 Integration: interpreting symbolic content

Purpose / when: integration sessions within days of a session. KPT used up to about 5 hours, with extra sessions over the following days.
Steps [source: Krupitsky et al. 2001]:
1. Read the written self-report together.
2. Explore the personal meaning of the symbolic content.
3. Connect it explicitly to the presenting problem.
4. Use it to strengthen the client's commitment to change.
5. Compare the experience with the prepared narrative: what confirmed it, what challenged it. [synthesis]
Example language (illustrative): "You wrote that you saw yourself at the end of a long corridor, alone. When in your life have you felt that?"
Watch for: the therapist supplying the meanings; spiritual content treated as literal fact (keep it as the client's own experience and framework). Working when: the client links images to concrete life issues.

4.14 Anchoring

Purpose / when: every integration session, both styles. Dore et al. describe "anchoring" the essential elements of the experience.
Steps [source: Dore et al. 2019; steps 3–4 synthesis]:
1. Identify the core gain: an understanding, a feeling or a shift.
2. Capture it in a portable form: a phrase or slogan, an image, a metaphor or a bodily feeling.
3. Agree when the client will recall it (cue situations) and what behaviour it should guide.
4. Review it at later sessions.
Example language (illustrative): "If you had to keep one sentence from today, what would it be? Where will you put it so you see it this week?"
Watch for: anchors that fade within days. Working when: the client spontaneously uses the anchor in difficult moments.

4.15 Integration through motivational interviewing and behavioural activation

Purpose / when: psychotherapy-only integration sessions. This was the base used by Field Trip Health, with other approaches added as needed. [source: Field Trip preprint]
Steps [synthesis applying standard MI/BA to integration]:
1. Evoke change talk from the session material.
2. Turn insights into specific valued activities, scheduled with the client.
3. Review progress and obstacles each week.
Example language (illustrative): "You felt your daughter mattered more than the bottle. What is one thing this week that would put that into action?"
Watch for: insight without behaviour change. Working when: activity and change talk increase between sessions.

4.16 Reviewing progress and deciding the next step

Purpose / when: after each session and integration cycle.
Steps:
1. Review symptom change and therapeutic progress with the prescriber. In Dore's model, moving to transformational sessions depends on these and is the provider's call. [source: Dore et al. 2019]
2. Watch the early months closely. In the KPT heroin trial nearly half the high-intensity group and 60% of the low-intensity group relapsed within three months, and the authors suggested further sessions might help. [source: Krupitsky et al. 2001]
3. Decide whether to continue in the same style, change style, continue psychotherapy without ketamine, or end. [synthesis]
Example language (illustrative): "Let's look at what has changed since the last session, and what hasn't, before we and the doctor decide what comes next."
Watch for: a client seeking more sessions mainly for the drug state itself (see 5). Working when: decisions follow the goals and are documented.

4.17 Contrast: plasticity-oriented adjunct therapy

Purpose / when: when the aim is not to use the experience but to deliver an established therapy outside the acute effects. [source: Mathai et al. 2022; Drozdz et al. 2022]
Forms reported: CBT (Wilkinson et al.), exposure/ERP (Rodriguez et al.; Adams et al.), prolonged exposure (Duek et al.; Shiroma et al.), mindfulness-based relapse prevention and motivational enhancement therapy (Dakwar et al.; Azhari et al.), TIMBER (Pradhan et al.), MBCT and FAP (Halstead et al.). [source: Drozdz et al. 2022; Mathai et al. 2022]
Steps: follow the standard manual for the chosen therapy; coordinate timing with the prescriber. [synthesis]
Watch for: confusing this with psycholytic work. Here the therapy does not take place in the altered state. Working when: there is the standard progress expected from that therapy.

4.18 Tracking experience and outcome

Purpose / when: intake, each session and termination.
Steps:
1. Standard symptom measures at intake and periodically (Dore's practices used depression and anxiety scales such as BDI, PHQ-9 and HAM-A). [source: Dore et al. 2019]
2. Session-experience measures: Dore's practices used the Mystical Experience Questionnaire and an ego-dissolution measure; KPT used the Hallucinogen Rating Scale and spirituality and meaning-in-life measures. Use licensed instruments under their own terms; items are not reproduced here. [source: Dore et al. 2019; Krupitsky et al. 2001]
3. Clinician ratings of effects, sensitivity, symptom change and adverse effects. [source: Dore et al. 2019]
Watch for: treating high mystical scores as success in themselves. Working when: data inform the review in 4.16.

4.19 Harm reduction and integration support for clients using ketamine outside supervised programmes

Purpose / when: clients who use ketamine illicitly, at home or through unmonitored services. The FDA has specifically raised concerns about at-home use without monitoring. [source: FDA warning via HealthDay]
Steps [synthesis]:
1. Assess frequency of use, motives, dependence features, bladder or urinary symptoms, and mental-state effects, without judgement.
2. Give general risk education: misuse and dependence, bladder harm, raised blood pressure, slowed breathing (especially combined with other sedating substances, in general terms only), accidents while impaired, and psychiatric reactions. [source: FDA-named risks]
3. Safety plan: not being alone, no driving, a trusted person, an emergency plan.
4. Refer to medical care or substance-use services where indicated; point to regulated, legal treatment options.
5. Offer integration sessions (4.13–4.14) for experiences that have already happened. Never give dosing, sourcing or facilitation advice.
Example language (illustrative): "I'm not going to tell you how to use it. I do want to help you stay safe and make sense of what you've been through."
Watch for: escalating frequency, using alone, urinary symptoms (urgent medical referral). Working when: risk behaviours decrease and the client engages with medical care.

4.20 Historical variants: not for use

Described as history only,. No administration detail is given.

Roquet (Mexico, early 1970s): combined ketamine with psychoanalytic techniques, Indigenous healing elements and group "sensory overload" to provoke and then process extreme experiences. [source: Mathai et al. 2022, citing Yensen 1973 and Wolfson 2014]
Khorramzadeh & Lofty (Iran, 1973): used ketamine to support "abreactive" processing of traumatic memories; follow-up work related personality to the type of drug experience. [source: Mathai et al. 2022]
Early KPT aversive component (USSR, from 1985): patients were made to smell alcohol at intense moments of the session so that drinking would become emotionally negative, before the model shifted to existential and transpersonal work. [source: Krupitsky & Grinenko; Mathai et al. 2022]
Why these matter today [synthesis]: recognise them when clients or practitioners describe them, and do not reproduce aversive pairing or deliberate overload. Ask clients who took part in such programmes about their experience, any lasting distress or aversion, and whether the ketamine state now acts as a trauma cue; offer trauma-informed integration or referral.

5. Handling problems

The sources say little about problem management. Items without a source tag are [synthesis].

Client cannot enter or use the trance state. Dore et al. report this especially with rigid personality structures (severe OCD, personality disorders, possibly severe PTSD). Response: more preparation focused on letting go of control (for example, practising non-striving attention in ordinary sessions); review with the prescriber; consider a plasticity-oriented approach (4.17) or psychotherapy without ketamine. [source: Dore et al. 2019; response is synthesis]
Non-response. Dore et al. estimate about 1–2% do not respond. Response: stop rather than escalate for its own sake; reformulate; refer for other evidence-based treatment. [source: Dore et al. 2019; synthesis]
Nausea, vomiting, agitation and physical intolerance. These are the most common adverse effects; under 5% cannot tolerate nausea even with preventive medication. Response: medical staff manage them; the therapist normalises them and helps with grounding. Persistent intolerance ends ketamine work. [source: Dore et al. 2019]
Overwhelm or terror in session. Response: see 4.10, including calming reassurance and redirection (KPT). Afterwards, process the fear itself in integration and revisit consent before any further session. Consider a lower-intensity style next time. [source: Krupitsky & Grinenko; synthesis]
Mismatch of stance. A client in a psychedelic-style session may feel abandoned by therapist silence; a client in trance may feel intruded upon by questions. Response: agree beforehand how often you will check in; in session follow the client's lead; repair in integration.
Ruptures linked to the warmer, more disclosing posture. Intensified attachment, idealisation or boundary confusion can follow. Response: name the dynamic in ordinary sessions; keep Dore's boundary of "not needing" the patient; seek supervision; never extend contact outside the frame. [source: Dore et al. 2019 for the posture; response synthesis]
Touch-related difficulties. No source sets out a touch policy [uncertain]. Response: touch only as agreed in writing beforehand, with ongoing consent; a second clinician present; stop at once if the client withdraws consent; document.
Trauma re-experiencing or flooding, especially in psycholytic work on trauma. Response: slow down, ground, shift to support; in integration, use trauma-informed stabilisation before returning to the material; reconsider the style.
Lingering derealisation or depersonalisation after a session. Derealisation is among the early effects Dore et al. report. Response: medical review if it persists; grounding skills; no further session until resolved. [source: Dore et al. 2019; synthesis]
Early relapse after a strong session (addictions). This was common within three months in KPT. Response: plan for it in advance; keep regular integration and relapse-prevention contact; review with the prescriber whether further sessions are indicated. [source: Krupitsky et al. 2001; synthesis]
Seeking the drug state rather than the therapy; misuse or dependence. The FDA lists abuse and misuse among ketamine's risks, and esketamine's REMS includes monitoring for it. Response: name the pattern, assess for dependence, involve the prescriber, refer to addiction care if needed; use 4.19 for outside use. [source: FDA warning via HealthDay]
Bladder or urinary symptoms. Response: urgent medical referral; do not continue ketamine work without medical clearance. [source: FDA-named risks]
Emerging suicidality or worsening mood. Response: standard structured risk assessment and safety planning; lethal-means counselling limited to safe storage and removal; involve the prescriber; pause ketamine sessions until reviewed.
Insight without behaviour change (non-adherence to integration). Response: re-anchor (4.14), use MI and behavioural activation (4.15), and agree small concrete commitments. [source: Dore et al. 2019; Field Trip preprint]
Spiritual or near-death content the client takes literally, or that distresses them. Response: explore it within the client's own framework without confirming or disputing metaphysical claims. Views such as Kolp's, that such experiences accelerate psycho-spiritual growth, are those authors' theory, not fact. Refer to the client's own faith community if they wish. [source: Sienknecht 2020 reporting Kolp]
Client distressed by having been asked to write the self-report or to share in a group. Response: offer alternatives (dictation, drawing, individual-only integration).
Destabilising worsening after leaving a supported setting. One reported OCD case worsened after discharge; Drozdz et al. attribute this to leaving the clinical environment. Response: plan the step-down of contact and keep integration sessions in place. [source: Drozdz et al. 2022]
Pressure to work outside the law or without medical supervision (from clients or employers). Response: decline; explain the regulatory position; offer harm-reduction and integration support only (4.19). [source: FDA warning via HealthDay; synthesis]
Clients harmed by historical or non-standard practices (aversive pairing, group overload, unsupervised "guides"). Response: see 4.20; trauma-informed assessment; help with complaints or reporting to regulators where appropriate.
No safe way home / no support person. This was a published exclusion. Response: do not proceed until arranged. [source: Field Trip preprint]

Sources

Sources:

Further reading (not drawn on): books and papers cited:

Kolp, E., Friedman, H. L., Krupitsky, E., Jansen, K., Sylvester, M., Young, M. S., & Kolp, A. (2014). Ketamine psychedelic psychotherapy: Focus on its pharmacology, phenomenology, and clinical applications. International Journal of Transpersonal Studies, 33(2). [uncertain: full text]
Wolfson, P., & Hartelius, G. (Eds.) (2016). The Ketamine Papers: Science, Therapy, and Transformation. MAPS. [uncertain]
Krupitsky, E. M., et al. (2002). Ketamine psychotherapy for heroin addiction: immediate effects and two-year follow-up. Journal of Substance Abuse Treatment. [cited via Drozdz et al. 2022 and Heffter Review version]
Krupitsky, E. M., et al. (2007). Single versus repeated sessions of ketamine-assisted psychotherapy for people with heroin dependence. Journal of Psychoactive Drugs. [cited via Drozdz et al. 2022]

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