TIMBER (ketamine with mindfulness-based extinction and reconsolidation)

1. Introduction

Version followed: the adult ketamine-augmented protocol of the Cooper University Hospital pilot trial (Pradhan et al., 2017; ClinicalTrials.gov NCT02766192, sponsor The Cooper Health System, PI Basant Pradhan, Camden NJ), with procedural detail taken from the developer's programme description on the CEBC (youth monotherapy version) and published summaries of the treatment manual (Pradhan, Pinninti & Rathod, 2019, TIMBER Psychotherapy: For PTSD, Depression and Traumatic Psychosis, Springer, Cham). The manual's bibliographic details and seven-chapter structure come from the Springer page, the registry's design and inclusion thresholds from the moreblossom registry summary, the drug-session staffing statement from the moreblossom paper summary, and US regulatory status from an FDA page. The manual's session scripts, the yoga content of the 2015 Y-MBCT book, the trial's exclusion criteria and any touch or team policy are not published in any of these sources, so the steps below that go beyond them are marked [synthesis] or [uncertain]. [source: OPEN Foundation and moreblossom summaries of Pradhan et al. 2017; moreblossom registry summary; CEBC programme profile; Springer book page; FDA 2023]

TIMBER (Trauma Interventions using Mindfulness Based Extinction and Reconsolidation of memories) is a manualised, mindfulness-based cognitive-behavioural psychotherapy developed by psychiatrist Basant Pradhan at Cooper University Health System. It can be delivered alone (first published with adolescents in 2015) or alongside medication; this guide concerns its combination with ketamine. The psychotherapy is the same in both forms; ketamine is an add-on given and monitored by the medical team. [source: Pradhan et al. 2015 abstract, Bentham; CEBC]

How change is thought to happen: the developers place trauma memories at the centre of PTSD. Extinction-only treatments (such as prolonged exposure) are seen as limited by tolerability and by "context-dependency" of the new learning. TIMBER therefore pairs extinction with reconsolidation: a trauma memory is briefly and controllably reactivated, which in the authors' model makes it temporarily changeable, and during that window the person practises mindful, non-reactive observation and cognitive-emotive reappraisal so the memory is re-stored with less arousal. Controlled reactivation replaces flooding. The authors' rationale for adding ketamine is that its rapid antidepressant and anti-PTSD effect is short-lived, and that TIMBER skills practised within the post-reactivation window might extend it. [source: moreblossom summary of Pradhan et al. 2017; CEBC; Bentham abstract] The neural mechanism is stated by the authors themselves to be speculative. [source: moreblossom summary]

Legal and regulatory status. United States (FDA, October 2023): ketamine hydrochloride is FDA-approved only as an anaesthetic agent. It is not approved for any psychiatric disorder, and FDA states it has not found ketamine safe and effective for conditions such as depression, anxiety, PTSD or OCD, so its use for PTSD is off-label. It is a Schedule III controlled substance. Compounded ketamine products (including oral and sublingual forms) are not FDA-approved for any indication and fall outside any REMS. FDA warns that unmonitored use, especially at home, risks sedation, dissociation and vital-sign changes, and lists abuse and misuse, psychiatric events or worsening, raised blood pressure, respiratory depression and lower urinary tract and bladder symptoms as known concerns. Esketamine (Spravato) is approved for treatment-resistant depression in adults and for depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behaviour; under its REMS it is dispensed and given only in certified, medically supervised settings, with post-dose monitoring by healthcare staff. Neither product is approved for PTSD. [source: FDA, "FDA warns patients and health care providers about potential risks associated with compounded ketamine", 10 October 2023] European Union: Spravato has held an EU marketing authorisation since 18 December 2019 for adults with treatment-resistant major depressive disorder, used together with an SSRI or SNRI and taken under the direct supervision of a healthcare professional; it has no EU authorisation for PTSD. [source: EMA, Spravato EPAR page] United Kingdom: ketamine has been a Class B drug under the Misuse of Drugs Act 1971 since 10 June 2014. [source: SI 2014/1106, legislation.gov.uk] US label changes after October 2023, ketamine's current schedule under the UK Misuse of Drugs Regulations and its controlled-drug status in individual EU states are not covered here. [uncertain: check current FDA and MHRA information and national law before use] The TIMBER-ketamine combination has been studied only in a small Phase II pilot under a research protocol. [source: moreblossom registry summary]

Practical consequence for a psychotherapist: you can learn and deliver TIMBER as a stand-alone psychotherapy. Delivering it alongside ketamine is only appropriate inside a medically run, legally compliant programme (research protocol or licensed clinic) where prescribing, administration and medical monitoring are the medical team's responsibility. Nothing in this guide covers how ketamine is given. [synthesis]

2. Framework

Sources describe two delivery frames; name which you are using.

A. Ketamine-augmented adult protocol (Pradhan et al., 2017; NCT02766192) [source: OPEN Foundation; moreblossom paper and trial summaries; Howard Brain Sciences Foundation blog, "TIMBER and Ketamine Infusion"]

Population: the registry (as summarised by moreblossom) specifies adults aged 21 to 60 with chronic PTSD by DSM-IV, a PCL-C score of at least 51 and a CAPS score (first 17 items) of at least 50; the paper summary adds treatment-refractory PTSD for at least 6 months despite CBT and at least two antidepressant trials. Registry details: Phase II, quadruple-masked, target enrolment 50 (published reports describe 10 and 20 randomised participants), start August 2013, status listed as unknown. [source: moreblossom registry and paper summaries] Exclusion criteria: not verified. The full paper (doi:10.4103/2542-3932.211589) and the related D-serine biomarker paper are not drawn on here, and the summaries list no exclusion criteria or screening procedures. [uncertain]
Design: randomised, placebo-controlled, crossover pilot. One arm received ketamine plus TIMBER, the other an inactive placebo plus TIMBER; placebo participants who had a sustained relapse (described in the blog as two weeks of relapse) crossed over to ketamine plus TIMBER. The pharmacist and statistician were unblinded; other study staff stayed blinded. Registry primary outcomes were change on CAPS and PCL about a day after the drug session, with Ham-D and BAI as secondary outcomes. [source: moreblossom paper and registry summaries]
Psychotherapy dose: 12 TIMBER sessions in total, three in the first week (the first falling within the ketamine session window, then day 2 and day 8, per the blog summary), followed by nine weekly sessions of about 40 to 45 minutes. The paper's Methods section also describes twice-daily home mini-TIMBER practice until relapse, then the nine weekly full sessions; the summaries note this is not fully reconciled with the abstract. [uncertain: exact sequencing]
Phase 1, preparation and baseline: diagnosis with CAPS and PCL; ASMI (mindfulness) baseline; MoCA (general cognition); C-SSRS (suicidality); Ham-D-17 and BAI; preparation of a brief scripted narrative of the index trauma. Teaching of STOPP and mini-TIMBER. [source: moreblossom paper summary; blog]
Phase 2, peri-ketamine module: two brief cycles of mini-TIMBER/STOPP during the window around the ketamine session, each combining short, controlled trauma-memory reactivation with rapid de-escalation and "mindful detached monitoring". The authors base this timing on a reconsolidation window of roughly the first six hours after controlled reactivation. An anaesthesiologist was present during drug sessions; medical monitoring was the medical team's job. [source: moreblossom paper summary]
Phase 3, consolidation: home mini-TIMBER practice and weekly full TIMBER sessions (MB-GET plus reconsolidation-based procedures). ASMI repeated after session 5 and at the end.
Phase 4, follow-up: monitoring for relapse over up to 18 months (one year in some passages). Response was judged against prespecified responder criteria on CAPS/PCL; the mean sustained response in the pilot was about a month. [source: OPEN Foundation; moreblossom]

B. Stand-alone outpatient version (CEBC developer description; youth 8 to 17, also used with adults) [source: CEBC]

8 to 12 sessions of 30 to 45 minutes over about 24 weeks, with spacing that widens: sessions 1 and 2 weekly, roughly sessions 3 to 6 fortnightly, the next two three-weekly, and the last two as monthly boosters. The blog summary of the manual describes about 15 sessions including three boosters. [uncertain: varies by source]
Early sessions (about 2): learn full TIMBER and mini-TIMBER in the office.
Middle sessions: full TIMBER moves from imaginal exposure in session, to home practice, to real-life (in vivo) exposure; mini-TIMBER used for daily triggers.
Booster sessions: consolidate and prevent relapse.
Caregivers act as co-therapists for young people, supporting home practice.
Setting: ordinary outpatient office. Developer-stated provider minimum: bachelor-level with some grounding in mindfulness and CBT; developer training is six hours over two days, onsite for a fee. [source: CEBC]

Criteria for moving between phases (sources give few explicit criteria; these are partly derived)

From preparation to reactivation work: client can run STOPP and a short mindfulness practice and bring arousal down in session; narrative script prepared. [synthesis, built on CEBC statement that clients can use both versions after about two training sessions]
From imaginal to home and in vivo exposure: ART-MR arousal during reactivation is falling across trials and the client can de-escalate without therapist help. [synthesis]
Personalising emphasis: re-score the ASMI at session 5 and adjust which mindfulness skills you lean on. [source: moreblossom; brainsciences blog]
Spacing out sessions and moving to boosters: PTSD scores at or near responder level and independent home practice logged. [synthesis]
Re-intensifying: sustained return of symptoms (relapse) prompts resumed sessions; in the trial it triggered crossover. [source: blog; moreblossom]

3. Guiding principles

[source for each, unless marked: CEBC; moreblossom and OPEN Foundation summaries of Pradhan et al. 2017; Bentham abstract; brainsciences blog posts]

Trauma memories are the target. Keep sessions focused on the index trauma memory and its triggers rather than general support.
Combine extinction with reconsolidation. Each piece of exposure work should both repeat safe contact with the memory and briefly reactivate it so it can be updated.
Controlled reactivation, not flooding. Keep exposure brief and titrated; stop and de-escalate before arousal becomes overwhelming. The stated aim is to avoid "flooding and re-traumatization" (brainsciences blog).
Measure arousal, do not guess. Use the clinician-rated ART-MR during reactivation; it lets you track arousal even when the client cannot report it verbally.
Mindful detached monitoring is the core skill. The client observes thoughts, sensations and images non-reactively while the memory is active.
Personalise the mindfulness. Use ASMI scores to choose and adjust components, and re-score over treatment.
Practice at home, every day. Gains are built by twice-daily routine practice plus as-needed use when triggered, recorded in a log.
Generalise from office to life. Move from imaginal to real-life exposure; use mini-TIMBER at the moment a trigger hits.
Reappraisal through cognitive-emotive restructuring. Meditation is framed by Pradhan as an "ongoing cognitive-emotive-reappraisal process" (brainsciences blog); use reactivated moments to form new meanings.
Biomarker-informed and measurement-based. Track standardised scales at set points; the developers present TIMBER as translational and biomarker-informed (Springer book page).
The drug is an adjunct, held by medicine. Where ketamine is used, the psychotherapy is unchanged and timed around it; administration and physiological monitoring sit with the medical team. [source: moreblossom; synthesis for division of roles]
Involve family where available. For young clients, caregivers act as co-therapists for home practice.
Culturally adapt. The manual devotes a chapter to cultural considerations; its guidance is not summarised here. [uncertain]

4. Intervention inventory

The component list below follows what the developer published on the CEBC, the 2015 and 2017 paper abstracts and summaries, and the Howard Brain Sciences Foundation summaries of the 2019 manual. The manual (seven chapters: traumatic memories and their neurobiology; TIMBER methodology; customisation and future directions; illustrations of the therapeutic process; cultural considerations; therapist training and policy) contains the step-by-step guide, client handouts and assessment tools; nothing from its chapter text is reproduced here. [source: Springer book page] No published step-by-step protocol outside the manual was found, so step sequences below are built from the named components and labelled [synthesis] where they go beyond the sources. Licensed instruments are described, not reproduced. All example language is illustrative.

4.1 Eligibility screening and informed consent (ketamine-augmented frame)

Purpose / when: before any work, to confirm the client fits the protocol and understands the psychotherapy, the ketamine component and the alternatives. [source: trial population in moreblossom summary]
Steps: (1) Confirm chronic PTSD with a structured interview (CAPS) and self-report (PCL) against the registry thresholds, and treatment history (prior CBT and at least two antidepressant trials, per the pilot's refractory definition). [source: moreblossom summaries] (2) Refer for medical and psychiatric screening by the prescribing team. The pilot's exclusion criteria are not given in the published summaries, so apply the treating programme's own published criteria rather than assuming the pilot's. [uncertain] (3) Baseline suicide risk assessment (C-SSRS was used in the trial) and cognitive screen (MoCA). (4) Consent conversation covering: that racemic ketamine is FDA-approved only as an anaesthetic and not for any psychiatric condition, so its use for PTSD is off-label [source: FDA 2023], and the evidence comes from a small pilot; that the drug part is handled and monitored by medical staff; what the TIMBER sessions involve, including brief trauma-memory reactivation; home practice expectations; right to stop. (5) Document. [synthesis for 4 and 5 except where tagged]
Example language (illustrative): "The talking and practice part is mine; the medication and your physical monitoring are the medical team's. Both teams talk to each other, and you can stop either at any point."
Watch for: expectation that the drug alone will cure; pressure from others to take part; active substance misuse or unstable psychiatric state, which you raise with the medical team. [synthesis]

4.2 Baseline assessment and personalisation with the ASMI

Purpose / when: at baseline, after about session 5 and at the end, to tailor the mindfulness components. [source: moreblossom summary; brainsciences blog]
What it is: the Assessment Scale for Mindfulness Interventions, an 18-item self-rated scale developed for this approach (items not reproduced). ASMI scores rose significantly after five sessions in the pilot. [source: brainsciences blog; moreblossom]
Steps: (1) Give the ASMI with the PTSD, depression and anxiety measures. (2) Note which mindfulness capacities score low. (3) Weight early training towards those (for example more focused-attention practice if attention control is weak). (4) Re-score at session 5; if no change, revise the practice plan and look at the meditation log for obstacles. [steps 2 to 4: synthesis on how scores are used; the manual's own decision rules are not published outside it]
Example language (illustrative): "This questionnaire shows where your mindfulness skills are strong and where we should build first."
Watch for: score rising alongside falling PTSD scores is the expected pattern; a flat ASMI with poor practice logs predicts slow progress. [synthesis]

4.3 Scripted brief narrative of the index trauma

Purpose / when: prepared at baseline; used as the standard cue for controlled reactivation in later sessions. [source: moreblossom summary; CEBC; brainsciences blog]
Steps: (1) Identify the index trauma (the memory driving most intrusions). (2) With the client, write a brief, present-tense or first-person account of its core moments, including sensory details and the worst point. (3) Keep it short enough to read in a minute or two. (4) Agree that it will be read aloud or listened to in session, with STOPP available at any time. [steps 2 to 4: synthesis; source describes it only as a brief scripted narrative]
Example language (illustrative): "We'll write a short version of what happened, just the key moments. We'll use it in small doses, not to relive the whole thing."
Watch for: a script too long or detailed for brief reactivation; a client who cannot tolerate writing it (start with a headline version). [synthesis]

4.4 Arousal monitoring with the ART-MR

Purpose / when: during every controlled reactivation, to keep arousal in a workable range and to measure change. [source: CEBC; brainsciences blog]
What it is: the Arousal Response to Trauma Memory Reactivation scale, clinician-rated, covering eleven observable bio-behavioural and cognitive-emotional responses (such as eye, heart-rate and breathing changes); it works without relying on what the client says. Items are not reproduced here. [source: brainsciences blog]
Steps: (1) Rate baseline before cueing the memory. (2) Rate during reactivation. (3) When ratings climb towards the client's threshold, move to STOPP. (4) Rate again after de-escalation and record. (5) Compare across sessions. [synthesis on sequence]
Watch for: sudden stillness, glazed eyes or flat responses can signal dissociation rather than calm; check verbally. Successful work shows lower peak ratings and faster return to baseline over sessions. [synthesis]

4.5 Focused-attention meditation

Purpose / when: early skill building, especially for clients with poor attention control; foundation for STOPP. [source: brainsciences blog, "The History and Efficacy of TIMBER", describing Pradhan's two meditation types]
Steps: Pradhan describes this as monitoring attention, noticing distraction, disengaging from it and redirecting attention. In practice: (1) choose an anchor such as the breath; (2) rest attention there; (3) when the mind wanders, notice it; (4) let go of the distraction; (5) return to the anchor; repeat. [source for the four elements; ordering as steps is synthesis]
Example language (illustrative): "Each time you notice you've drifted and come back, that's the exercise working, not failing."
Amount of practice: the manual summary recommends short, regular daily practice kept up over several weeks. [source: brainsciences blog]
Watch for: practice logged daily; increasing ease of returning attention. [synthesis]

4.6 Open monitoring and mindful detached monitoring

Purpose / when: the core stance used while a trauma memory is active, in full TIMBER, mini-TIMBER and the peri-ketamine module. [source: moreblossom summary ("mindful detached monitoring"); brainsciences blog (open monitoring)]
Steps: Open monitoring is described as "nonreactive, moment-to-moment monitoring of the content of experience" (brainsciences blog). In practice: (1) widen attention from a single anchor to whatever arises; (2) label experiences briefly (image, thought, body sensation, urge); (3) observe them as passing events without engaging, arguing or pushing away; (4) when absorbed, return to observing. [steps 2 to 4: synthesis]
Example language (illustrative): "See if you can watch the image as if it's on a screen across the room. Notice it, name it, and let the next thing come."
Watch for: the client can describe the memory while remaining an observer; dropping ART-MR ratings during the same exposure. [synthesis]

4.7 STOPP (rapid de-escalation)

Purpose / when: used together with ART-MR to bring arousal down during reactivation and in daily life, so as to avoid flooding and retraumatisation. [source: brainsciences blog]
Steps: The manual summary expands the acronym as Stress, Three mindful breaths, Observe, Practice more, Proceed. [source: brainsciences blog; the manual's own instruction wording is not reproduced] Working version: (1) Stress: recognise and name that stress or a trigger has arrived. (2) Three mindful breaths: take three slow breaths with full attention on each. (3) Observe: notice sensations, thoughts and emotions with detached monitoring. (4) Practice more: if still highly aroused, continue the practice (more breaths, more observing) until arousal settles. (5) Proceed: return to the task or exposure. [expansion of each step: synthesis]
Example language (illustrative): "Stop for a moment. You've noticed the stress. Three slow breaths with me. Now just observe what's here."
Watch for: the client initiating STOPP without prompting; ART-MR falls within a minute or two. If breathing practice increases panic (some clients find breath focus triggering), shift the anchor to feet or hands. [synthesis]

4.8 Controlled reactivation of the trauma memory

Purpose / when: the reconsolidation step; opens the memory so it can be updated, used in every full TIMBER session and in the peri-ketamine cycles. TIMBER "uses controlled reactivation (rather than over-flooding)" (CEBC). [source: CEBC; moreblossom]
Steps: (1) Check readiness: client can perform STOPP; baseline ART-MR recorded. (2) Cue the memory briefly using the scripted narrative. (3) Hold contact only for a short period while the client uses detached monitoring. (4) Rate ART-MR. (5) Move to STOPP before arousal peaks out of the workable range. (6) Rate again, then debrief briefly about what was noticed. [steps: synthesis built on CEBC components and the 2017 description of "short" reactivation with "rapid de-escalation"]
Example language (illustrative): "I'll read the first part of the script. Let the memory come just enough to feel it, and watch it. When I say 'STOPP', we'll breathe together."
Watch for: a falling ART-MR peak across cycles; new details or meanings surfacing (material for restructuring); signs of dissociation or overwhelm (see section 5). [synthesis]

4.9 Full TIMBER session: mindfulness-based graded exposure therapy (MB-GET)

Purpose / when: the main in-office session (about 40 to 45 minutes) focused on memory extinction and therapist-assisted MB-GET; weekly in the consolidation phase. [source: CEBC; blog]
Steps (suggested session structure): (1) Review home-practice log and week's triggers (5 min). (2) Brief focused-attention practice to settle (5 min). (3) Graded exposure: work up a hierarchy of trauma cues, using the scripted narrative and, later, related reminders, with detached monitoring throughout and STOPP between steps (20 to 25 min). (4) Cognitive-emotive restructuring of what came up (see 4.11). (5) Plan home practice and any real-life exposure tasks (5 min). [session structure: synthesis; the manual's session-by-session content is not drawn on here]
Progression: imaginal exposure in session, then home practice, then real-life exposure. [source: CEBC]
Example language (illustrative): "Last week the courtroom part was a 6 out of 10. Let's go a step further today and stay with the moment you heard the verdict."
Watch for: habituation within and across sessions; widening range of cues the client can face; avoidance falling in daily life. [synthesis]

4.10 Mini-TIMBER (brief self-help practice)

Purpose / when: a roughly 5-minute, reconsolidation-based practice for use at home and when daily-life cues trigger PTSD arousal; aims to de-escalate quickly "so that new learning can occur". Clients start it as soon as an anxiety episode begins. [source: CEBC]
Steps: (1) Notice the trigger and its intrusion (that brief, naturally occurring reactivation is the opening). (2) Run STOPP. (3) Spend a few minutes in detached monitoring of the memory and body. (4) Add a brief reappraisal or new perspective rehearsed in session. (5) Log it. [steps 1, 3 to 5: synthesis; the manual's own sequence for mini-TIMBER is not published outside it]
Schedule of practice: twice daily routine practice (morning and evening, the evening one roughly two hours before bed) plus 3 to 4 as-needed uses daily, on a standard log. [source: CEBC] In the ketamine trial, home mini-TIMBER was practised twice daily until relapse. [source: moreblossom]
Example language (illustrative): "The moment you feel the jolt, that's your cue for mini-TIMBER. Five minutes, then write it in the log."
Watch for: shorter episodes and fewer uses needed over weeks; the client reports the memory feels "further away". [synthesis]

4.11 Cognitive-emotive restructuring and reappraisal

Purpose / when: after reactivation, to modify trauma meanings; the 2015 paper describes reappraisal and modification of trauma experiences through cognitive-emotive restructuring, alongside CBT techniques. [source: Bentham abstract]
Steps: (1) Ask what the client noticed during reactivation (thoughts, appraisals, body). (2) Identify a key appraisal (for example self-blame, ongoing danger). (3) Examine it with standard CBT questioning while the memory is still "warm". (4) Formulate an updated statement. (5) Rehearse it briefly during the next reactivation cycle or in mini-TIMBER. [steps: synthesis using generic CBT; the manual's specific restructuring techniques are not published outside it]
Example language (illustrative): "When you watched that moment just now, what did it say about you? And what do you know now that you didn't know then?"
Watch for: belief ratings for the appraisal falling; less shame or self-blame language. [synthesis]

4.12 Standardised yoga and meditation techniques

Purpose / when: to build regulation and new learning; the sources say TIMBER uses standardised yoga and meditation techniques drawn from Pradhan's Yoga and Mindfulness Based Cognitive Therapy (Y-MBCT). [source: Bentham abstract; brainsciences blog]
Steps: no published protocol outside the books. The publisher describes the 2019 manual as a step-by-step guide with reproducible client handouts, assessment tools, case examples and separately sold videos, and Pradhan's 2015 Y-MBCT book is named as the source of the yoga components; neither is summarised here. The specific postures, breathing practices and sequences are therefore not given. [uncertain] If you use body or breath practices, choose gentle, standard ones you are trained in and check medical limits. [synthesis]
Watch for: physical discomfort, breath-related panic; adapt or omit. [synthesis]

4.13 Real-life (in vivo) exposure

Purpose / when: generalisation, after imaginal work is tolerated. [source: CEBC]
Steps: (1) Build a list of safe, avoided reminders (places, sounds, activities). (2) Grade them. (3) Assign one or two between sessions with STOPP and detached monitoring available. (4) Review in the next session. [steps: synthesis] Only use reminders that are objectively safe; exclude real ongoing danger. [synthesis]
Example language (illustrative): "This week, drive past the junction once, use STOPP before and after, and note your arousal."
Watch for: completion and falling distress; safety-seeking behaviours that undermine learning. [synthesis]

4.14 Home-practice and meditation log

Purpose / when: throughout, to track practice and obstacles. [source: CEBC; brainsciences blog (meditation log records duration and obstacles)]
Steps: (1) Give a simple log (date, time, routine or as-needed, duration, trigger, arousal before and after, obstacles). (2) Review at the start of every session. (3) Problem-solve obstacles. [field list: synthesis]
Watch for: gaps in logging as an early sign of avoidance or non-adherence (see section 5).

4.15 Caregiver as co-therapist (youth version)

Purpose / when: for children and adolescents, when caregivers are available, to support home practice and generalisation. [source: CEBC]
Steps: (1) Invite the caregiver to part of the first two sessions to learn STOPP and mini-TIMBER. (2) Agree how they will prompt practice without pressure. (3) Check in briefly at each session. [steps: synthesis]
Example language (illustrative), to a parent: "Your job isn't to make them talk about it, just to remind them to do the practice and to do it alongside them if they want."
Watch for: over-involvement or a caregiver who is part of the trauma (do not use as co-therapist; assess safeguarding). [synthesis]

4.16 Peri-ketamine mini-TIMBER/STOPP module (ketamine-augmented frame only)

Purpose / when: the component that links psychotherapy to the drug session. Two brief cycles of controlled trauma-memory reactivation, each followed by rapid de-escalation and mindful detached monitoring, carried out within the window around the ketamine session; the authors tie this to an assumed reconsolidation window of about six hours after reactivation. In the trial the first TIMBER session took place within the drug session itself. [source: moreblossom summary of Pradhan et al. 2017; blog "TIMBER and Ketamine Infusion"]
Roles: an attending anaesthesiologist was present during drug sessions and authorised to treat marked rises in blood pressure or heart rate (none occurred), with "standard peri-procedure monitoring" [source: moreblossom paper summary]. Prescribing, administration, physiological monitoring and medical decisions rest entirely with medical staff. The summary refers to "therapist-guided reactivation" but does not say who delivered TIMBER in the session or how many staff were present. The psychotherapist runs only the reactivation and de-escalation cycles and stops whenever the medical team indicates. [division of roles: synthesis]
Steps: (1) Agree beforehand with the client and medical team when the cycles will be offered, and that the client may decline on the day. (2) Rehearse STOPP and the narrative cue in the preparation session so the client knows them well. (3) At the agreed point, check the client is oriented and able to engage; if not, skip and note it. (4) Cue the memory briefly; guide detached monitoring; rate ART-MR. (5) Move to STOPP; return to baseline. (6) Repeat once. (7) Hand back to medical observation. [steps 1, 3, 7: synthesis; how the trial handled altered states during cycles is not described in the sources] [uncertain]
Example language (illustrative): "Only if you're up to it: let a little of the memory in now, and watch it from a distance. Good. STOPP, three breaths."
Watch for: dissociative or perceptual effects of the drug making reactivation confusing or frightening; do not push. No intolerable side effects or dropouts were reported in the pilot; two participants had mild, self-limiting nausea, and there was no marked rise in blood pressure or heart rate. [source: moreblossom summary]
Touch and conduct: none of the published sources (moreblossom paper and registry summaries, OPEN Foundation summary, Howard Brain Sciences Foundation posts, CEBC profile) describes a touch policy, chaperone or two-therapist team for the drug sessions. [uncertain] Recommended: no physical touch beyond what medical staff need for care, a second staff member present throughout, and a written conduct and boundaries agreement agreed before the session. [synthesis]

4.17 Post-ketamine debrief and early TIMBER sessions

Purpose / when: the early follow-up sessions (the blog describes sessions on day 2 and day 8 after the drug session) consolidate what was experienced and restart home practice. [source: blog; content of these sessions not described, so steps are synthesis]
Steps: (1) Ask what the client remembers from the drug session and the cycles, and how they make sense of it, without adding interpretation. (2) Check mood, sleep, suicidality and any perceptual after-effects; pass medical concerns to the prescriber. (3) Re-establish twice-daily mini-TIMBER. (4) Begin or resume full TIMBER work if the client is settled. [synthesis]
Example language (illustrative): "Some people find the memory feels different after that day. What, if anything, has changed for you?"
Watch for: rapid symptom relief followed by fade (the authors note ketamine's effect alone is short-lived); use this window to build practice habits. [source for short-lived effect: blog; rest synthesis]

4.18 Measurement-based monitoring, relapse detection and booster sessions

Purpose / when: throughout and in follow-up. [source: CEBC; moreblossom; OPEN Foundation]
Steps: (1) Track PTSD (CAPS and/or PCL), depression (Ham-D-17 or a self-report equivalent) and anxiety (BAI) at baseline and set points. (2) Define in advance what counts as response and as relapse, so decisions are not ad hoc (the trial used prespecified responder criteria, and a sustained relapse triggered crossover). (3) Space out sessions as gains hold, ending with monthly boosters (stand-alone version). (4) Where relapse occurs, return to weekly full TIMBER; any decision on further medication is the prescriber's. [steps 1 to 3 source-based; 4 synthesis]
Watch for: relapse warning signs such as rising avoidance, dropping practice and new triggers. [synthesis]

4.19 Safety monitoring (suicidality and cognition)

Purpose / when: at baseline and regularly. The trial used the C-SSRS for suicidality and the MoCA to check that general memory was not affected; no suicidal behaviour, psychiatric hospitalisation or clinically significant cognitive effects were reported. [source: moreblossom; OPEN Foundation]
Steps: follow standard structured risk assessment at each contact during the intensive phase and whenever mood drops; agree a written safety plan; involve the prescriber in any risk change. [synthesis following standard practice]
Watch for: mood drop as the drug effect fades; hopelessness when relief does not last. [synthesis]

4.20 Harm-reduction and integration support for clients using ketamine outside a programme

Purpose / when: a client tells you they use ketamine from an unregulated source or a clinic you are not part of and wants to use TIMBER skills with it. TIMBER sources do not address this. [synthesis]
Steps: (1) Do not facilitate, time or coach drug use, and do not run reactivation alongside unsupervised use. (2) Assess pattern of use, medical and psychiatric risks, and dependence or bladder symptoms in general terms; refer to a physician. (3) Give general risk education (mixing with alcohol or sedatives, unsafe settings, dependence), without dosing. (4) Offer stand-alone TIMBER in sober sessions. (5) Refer to a regulated programme if medication treatment is wanted. [synthesis]
Example language (illustrative): "I can't guide you through it while you're using, but I can teach you the TIMBER skills sober, and help you look at safer options with a doctor."

5. Handling problems

The published sources address problems only through the design principle of controlled reactivation (to prevent flooding and retraumatisation) and through STOPP and ART-MR. Everything else below is [synthesis] unless tagged.

Overwhelm or flooding during reactivation. Stop the cue; run STOPP; if arousal stays high, ground through the senses (name what you see and hear, feet on the floor); next time shorten the cue and lower the hierarchy step. Controlled reactivation and STOPP with ART-MR are the source-based responses. [source: CEBC; brainsciences blog; grounding is synthesis]
Dissociation (blank, frozen, unreachable). Treat flat ART-MR signs with poor contact as dissociation, not calm. Open the eyes, orient to the room, use the client's name and simple questions; return to focused-attention practice before further exposure. With prominent dissociation, spend longer on stabilisation first. [synthesis]
Avoidance and resistance to exposure. Revisit the rationale (memory as target, small doses), let the client set the next step size, and start from the briefest headline version of the narrative. [synthesis]
Stuck: arousal does not fall across sessions. Check whether the client is reactivating the actual index memory or a safer version; check for safety behaviours; re-score the ASMI and shift towards whichever mindfulness skill is weakest; add cognitive restructuring of the hot appraisal. [synthesis; ASMI re-scoring is source-based]
Non-adherence to home practice. Review the log; shrink the routine to what is doable (the full mini-TIMBER is only about 5 minutes [source: CEBC]); tie practice to existing daily routines; use a caregiver as co-therapist for young people [source: CEBC]. [synthesis otherwise]
Meditation-related adverse effects. Mindfulness practice can sometimes increase anxiety, bring intrusive re-experiencing, depersonalisation or, rarely, psychotic symptoms in vulnerable people. Ask about these at each review; shorten or switch to eyes-open, externally focused practice; pause and re-assess if psychotic or severe dissociative symptoms appear. TIMBER's authors also apply it in traumatic psychosis; their adaptation is not described here. [synthesis; uncertain for the psychosis adaptation]
Breath practice triggers panic. Shift the anchor of STOPP from breath to touch points or sounds. [synthesis]
Ruptures. If the client feels pushed, name it, apologise for pace, return control of the hierarchy to them, and repair before resuming exposure. [synthesis]
Fade of ketamine benefit and disappointment. The authors describe ketamine's benefit alone as short-lived; prepare clients for this at consent, frame TIMBER practice as the means of holding gains, and monitor mood and suicidality closely as relief fades. [source for short-lived effect: blog; rest synthesis]
Client requests more drug sessions or wants to self-source. Medication decisions are the prescriber's; for outside use, follow the harm-reduction role in 4.20. [synthesis]
Acute drug-session effects (confusion, distress, physical symptoms). These are for medical staff; stop psychotherapy cycles and defer to them. [synthesis]
Suicidality rising. Full structured risk assessment, safety plan, lethal-means counselling (safe storage and removal), involve prescriber and crisis services as indicated. [synthesis following standard practice]
Cultural mismatch with yoga or meditation framing. The manual has a chapter on cultural considerations, not summarised here. Present practices in secular, skills-based language unless the client wants a spiritual framing, and invite the client's own traditions. [uncertain for the manual's guidance; rest synthesis]
Ongoing danger or current abuse. Exposure to reminders is not appropriate where the threat is real; prioritise safety planning and safeguarding duties. [synthesis]

Sources

Sources used:

Also cited:

Pradhan, B., Pinninti, N. R., & Rathod, S. (2019). TIMBER Psychotherapy: For PTSD, Depression and Traumatic Psychosis. Springer, Cham. doi:10.1007/978-3-030-20648-2 (Treatment manual; bibliographic details and chapter list from the publisher page.)
Pradhan, B. K., Wainer, I. W., Moaddel, R., Torjman, M. C., Goldberg, M., Sabia, M., Pumariega, A. J., et al. (2017). TIMBER psychotherapy pilot randomised placebo-controlled crossover trial with ketamine in PTSD and comorbid depression. Asia Pacific Journal of Clinical Trials: Nervous System Diseases, 2(3), 80. doi:10.4103/2542-3932.211589 (used through the OPEN Foundation and moreblossom summaries).
Pradhan, B., Gray, R., Parikh, T., Akkireddi, P., & Pumariega, A. (2015). TIMBER as monotherapy for chronic PTSD: a pilot study. Adolescent Psychiatry, 5(2), 125–131. doi:10.2174/221067660502150430155038 (abstract).
Pradhan, B. (2015). Yoga and Mindfulness Based Cognitive Therapy: A Clinical Guide. Springer. (Named by the developers as the source of the yoga and meditation components.)

Remaining [uncertain] points: the trial's exclusion criteria; any touch policy or therapist-team structure in drug sessions; the manual's session-by-session scripts, Y-MBCT yoga and breathing content, and the psychosis and cultural adaptations; US label changes after October 2023, ketamine's UK schedule and its national status in EU states.

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