Intravenous ketamine infusion clinics

1. Introduction

Version followed: for the clinic safety frame, the APA Council of Research Task Force consensus statement (Sanacora et al., 2017, JAMA Psychiatry). For team-based care and aftercare, the ASKP3 interdisciplinary Delphi consensus guidelines (McInnes et al., 2026, J Affect Disord), read only through a published summary. For psychotherapy, the protocols of the trials that paired infusions with a named therapy: CBT (Wilkinson et al., 2017 and 2021), MBRP and MET (Dakwar et al., 2019 and 2020), relapse-prevention therapy with mindfulness (Grabski et al., 2022), and TIMBER (Pradhan et al., 2017). Australia/NZ practice follows the RANZCP Clinical Memorandum (v4.0, July 2022). Esketamine follows the FDA label and Medication Guide (revised 09/2026).

An intravenous ketamine infusion clinic is a service model, not a psychotherapy. A medical team gives ketamine, mostly off-label, for mood and other psychiatric conditions. No founder or manual defines it. The APA statement presents itself as expert opinion, not a practice guideline [source: Sanacora 2017]. This guide covers the psychotherapist's role around the clinic: assessment and referral, consent support, preparation, outcome and risk monitoring, integration, adjunctive structured therapy, and joint working. It does not cover running the clinic. Everything about the drug itself is the medical team's job: prescribing, medical screening, administration and physiological monitoring. This guide gives no doses, routes, rates or schedules.

How change is thought to happen. Trial authors suggest ketamine opens a short period of greater neuroplasticity and cognitive flexibility. They also suggest it reduces barriers such as craving, low motivation and reactivity. Psychotherapy given in or after that period can then consolidate the drug's rapid but often short-lived effect into lasting learning [source: Wilkinson 2021 via study summary; Dakwar trials via BBRF summary]. In the psychedelic-oriented view, the dissociative experience itself helps therapy: it may build rapport, lower defensiveness and bring insight. In the non-psychedelic view, those effects are kept to a minimum. The literature has no agreed model [source: Drozdz et al. 2022]. ASKP3 states that infusions should never be given in isolation. They should come with psychological aftercare and, where appropriate, psychotherapy [source: ASKP3 2026 via Psychiatric Times].

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

USA: Racemic ketamine is a Schedule III controlled substance approved as an anaesthetic. Psychiatric use is off-label, and consent must say so [source: Sanacora 2017; ASKP3 via Osmind]. Esketamine (Spravato) is FDA-approved for treatment-resistant depression and for depressive symptoms in adults with MDD and suicidal thoughts or behaviour. It is restricted under a REMS: it may be given only in certified healthcare settings, outpatients must be enrolled, a healthcare provider observes the patient until judging them ready to leave, and someone else must drive them home. It is not a substitute for hospitalisation [source: FDA Spravato label/Medication Guide, rev. 09/2026].
Australia/NZ: Ketamine is approved as an anaesthetic (TGA/Medsafe), and only esketamine is approved for TRD. Ketamine is Schedule 8 in Australia and Class C in NZ. A psychiatrist, or a doctor supervised by one, must prescribe it and stays responsible for the whole treatment process [source: RANZCP CM 2022].
England/Wales: NICE TA854 does not recommend esketamine for TRD within the NHS [source: NICE TA854]. Status of racemic ketamine clinics in the UK, Canada and the EU: [uncertain] (no primary source opened).

2. Framework

No source gives a single phase model for IV clinics. The phases below combine the APA, ASKP3 and RANZCP safety frame with the psychotherapy trial designs. The labels are [synthesis]; the content of each phase is sourced.

Phase A: Assessment and referral decision. Goal: decide whether a referral is appropriate and safe. The APA statement asks for a comprehensive diagnostic assessment covering substance-use and psychotic-disorder history. It also asks for baseline symptom ratings, documented adequate prior treatment trials, medical review and records. Family corroboration and baseline urine toxicology are strongly encouraged [source: Sanacora 2017]. RANZCP requires assessment by a psychiatrist with ketamine expertise [source: RANZCP CM 2022]. Psychotherapist's share: psychological history, a diagnostic opinion, baseline measures and treatment history, shared with the prescriber (with consent). Move on when the prescriber accepts the referral and medical screening is complete.

Phase B: Consent and preparation (therapy, typically 1–2 sessions [synthesis]). Goal: an informed, documented consent and a prepared client. Consent covers off-label status, limited evidence, risks, alternatives, cost, that outcomes are not guaranteed, and that ketamine is "a treatment, not a cure" [source: Sanacora 2017; ASKP3; RANZCP]. Preparation before ketamine is a shared theme across models [source: Drozdz 2022]. Move on when consent is documented and the client has a coping plan, transport and a crisis plan.

Phase C: Infusion course (medical team leads; psychotherapy alongside). Goal: safe treatment with symptoms tracked. The prescriber sets and limits the course. The APA statement advises the fewest treatments needed for response, aiming at eventual taper and stopping [source: Sanacora 2017]. Psychotherapy during this phase depends on the protocol: brief integration contacts, or a structured therapy running alongside (see Section 4).

Phase D: Consolidation (structured therapy, e.g. 14 weeks of CBT in Wilkinson 2021). Goal: turn early response into lasting change once ketamine stops or is spaced out. In Wilkinson 2021, only people who had responded to the initial infusions went into CBT, which ran after the infusion phase [source: Wilkinson 2021 via study summary].

Phase E: Ongoing review, maintenance decision or discharge. Goal: reassess risk and benefit regularly. Each further treatment must be justified by benefit. Cognition, urinary symptoms and substance use are monitored. Non-response may mean further treatment is futile, though no clear cutoff is set [source: Sanacora 2017; RANZCP 2022]. Move to discharge or another treatment when there is no response, when harms appear, or when gains are stable.

Format. Psychotherapy is individual in all the sourced protocols, delivered by trained therapists (psychologists or certified CBT therapists). It sits in a team-based model with medical and psychiatric competence [source: ASKP3 via Psychiatric Times; Grabski 2022 via PPI; Wilkinson 2021].

3. Guiding principles

Team-based care, never infusion alone. Have a named role and a communication channel with the clinic before the first infusion [source: ASKP3 2026].
Stay in your scope. Dosing, medical screening and in-session monitoring belong to the medical team. You never advise on drug matters; you route those questions to the prescriber [source: Sanacora 2017; RANZCP 2022].
Off-label honesty. Repeat that evidence is limited, mostly short-term, and that outcomes are not guaranteed. This counters unrealistic hope [source: Sanacora 2017; RANZCP 2022].
"A treatment, not a cure." Present infusions as one part of a plan, with psychological work carrying the gains forward [source: ASKP3 via Psychiatric Times].
Measurement-based care. Use the same rating instrument at baseline and throughout. Share scores with the prescriber, because continued treatment depends on shown benefit [source: Sanacora 2017; ASKP3].
Minimum necessary exposure. Support the plan to taper and stop. Do not collude with requests for more frequent infusions [source: Sanacora 2017].
Vigilance for misuse. Ketamine can be misused. Ask routinely about other ketamine sources and other clinics [source: Sanacora 2017; FDA label].
Use the window, but do not oversell it. Schedule structured therapy close to the infusion course as the trials did. Tell clients the 'window' is a hypothesis [source: Wilkinson 2021; Dakwar trials; Drozdz 2022].
Choose the therapy by diagnosis. CBT/BA for depression, MBRP/MET for substance use, exposure or TIMBER for PTSD, ERP for OCD. Follow that therapy's own rules [source: Drozdz 2022].
Suicide risk is continuous. The rapid relief may not last, and antidepressant-class warnings apply. Re-assess risk at each contact [source: Sanacora 2017; FDA label].
Respect setting rules. Supervised administration only. The APA statement strongly discourages at-home self-administration, and ASKP3 does not support unsupervised parenteral use [source: Sanacora 2017; ASKP3 via Osmind].
Involve family if the client wishes. Use them for corroboration, transport and early warning [source: RANZCP 2022; Sanacora 2017].

4. Intervention inventory

The items below are what a psychotherapist does around an infusion clinic. Items 1–6 and 12–16 are the shared service frame. Items 7–11 are the named psychotherapies that trials have paired with infusions. All example wording is illustrative, written for this guide.

1. Pre-referral psychological assessment

Purpose / when: Before any referral, or when a client asks about ketamine. It gives the prescriber the history the APA statement requires [source: Sanacora 2017].
Steps:
1. Confirm the diagnosis and the current episode. Strongest evidence: a major depressive episode without psychotic features in MDD [source: Sanacora 2017]. Esketamine's licensed indications are narrower [source: FDA label].
2. Take a detailed history of substance use, including any past ketamine, other dissociatives, opioids and benzodiazepines, plus any history of psychosis [source: Sanacora 2017].
3. Document prior treatments and whether each was an adequate trial (medication and psychotherapy) [source: Sanacora 2017].
4. Record baseline severity on a standard instrument the clinic also uses (e.g. MADRS, QIDS, PCL-5; do not reproduce items) [source: Sanacora 2017; Wilkinson 2021].
5. Do a full suicide risk assessment and record the current safety plan.
6. Note cognitive complaints and any urinary or bladder symptoms, since both are monitored later [source: RANZCP 2022; Sanacora 2017].
7. With consent, send a referral letter to the prescriber and get collateral history from family if the client agrees.
Example language (illustrative): "Before I write to the clinic, I need a clear picture of what you've already tried, and anything you've used to change how you feel, including ketamine or other drugs. They'll ask, and it affects safety."
Watch for: A client who has already been to other ketamine providers; a history of psychosis or mania; hoping ketamine will replace needed hospital care [source: FDA label]. Medical red flags (vascular disease, uncontrolled hypertension, pregnancy) go to the prescriber, who decides [source: FDA label; RANZCP 2022].

2. Joint-working agreement with the clinic

Purpose / when: Before the first infusion. It puts in place the team-based model ASKP3 calls for and the role clarity RANZCP asks service policies to define [source: ASKP3 2026; RANZCP 2022].
Steps [synthesis, built on those requirements]:
1. Name the prescriber responsible for the whole treatment process and the on-site clinician responsible for discharge [source: RANZCP 2022; Sanacora 2017].
2. Agree how scores, risk changes and adverse events pass both ways, and how fast.
3. Agree who contacts whom if suicide risk rises between infusions, and the route for rapid psychiatric follow-up [source: Sanacora 2017].
4. Agree whether you attend infusions or only see the client before and after. Get the client's written consent to share information.
Example language (illustrative): "Can we agree that I send you a QIDS score and a short note after each of my sessions, and that you tell me the same day if anything happens during an infusion?"
Watch for: Clinics with no psychiatric evaluation, no outcome tracking or no aftercare. ASKP3 treats these as below standard [source: ASKP3 via Psychiatric Times].

3. Consent support conversation

Purpose / when: After referral and before the clinic's formal consent. It helps the client weigh the decision. The prescriber still obtains the written consent [source: Sanacora 2017].
Steps:
1. Go through the topics consent must cover: off-label status (or REMS rules for esketamine), limited and mostly short-term evidence, known risks, alternatives, cost, and that outcomes are not guaranteed [source: Sanacora 2017; RANZCP 2022; FDA label].
2. Give general information on the experiences and risks listed in official sources: dissociation, sedation, blood-pressure rise, abuse potential, cognitive and bladder effects. Driving is impaired until the next day after restful sleep, and someone else must drive them home [source: FDA label; Sanacora 2017].
3. Check that the client is willing and able to consent, and invite family involvement if they wish [source: RANZCP 2022].
4. Write down the client's questions for the prescriber.
Example language (illustrative): "Ketamine is a treatment, not a cure. The clinic will explain the medical side. What matters here is what you hope it will change, and what we'll do to keep that change going."
Watch for: Hopes of a cure or of never needing therapy again; pressure from family or clinic marketing.

4. Preparation session

Purpose / when: Within the week or so before the first infusion [synthesis on timing]. Preparation is a shared theme across ketamine-psychotherapy models [source: Drozdz 2022]. In some protocols the structured therapy starts before the first infusion: a CBT session before infusion for OCD [Rodriguez 2016], and MET before the infusion for cannabis use disorder [Azhari 2021] [source: Drozdz 2022].
Steps [synthesis unless tagged]:
1. Explain in plain terms what the client may notice: altered perception, feeling detached from the body or surroundings, emotional changes. Say these effects pass and that staff will monitor them. Leave the medical detail to the clinic.
2. Help the client set a focus for treatment linked to their therapy goals (e.g. one behaviour to re-engage in, one belief to test).
3. Agree a grounding plan for distressing moments (breath awareness, naming something physical, telling staff). Practise it once in session.
4. Confirm practicalities: an escort home, no driving or alcohol/other substances as the clinic advises, and a way to reach a clinician quickly afterwards [source: Sanacora 2017; FDA label].
5. Book the first integration or therapy session close after the infusion.
Example language (illustrative): "If things feel strange or frightening, you don't have to fight it or work it out there and then. Tell the staff, use the breath we practised, and bring it here afterwards."
Watch for: High anticipatory anxiety; a trauma history where dissociation may echo past experiences (plan extra grounding and an early integration slot) [synthesis].

5. Measurement-based monitoring

Purpose / when: At baseline, through the course and in follow-up. Continued treatment depends on shown benefit, and non-response may mean futility [source: Sanacora 2017; ASKP3 via Psychiatric Times].
Steps:
1. Give the agreed rating scale at each therapy contact and send it to the prescriber.
2. Ask regularly about cognition, urinary symptoms and substance use, including ketamine from other sources [source: Sanacora 2017; RANZCP 2022].
3. Watch for serotonin or withdrawal symptoms if oral antidepressants are being changed at the same time, and report them [source: RANZCP 2022].
4. Graph scores with the client to separate early relief from lasting change.
Example language (illustrative): "Let's look at your scores since we started. The first week dropped a lot; the question now is what holds steady."
Watch for: Scores bouncing back quickly between infusions (dependence on the infusion; therapy needs to work on the gap); no change after an adequate course. Raise either with the prescriber.

6. Integration session (supportive processing)

Purpose / when: Soon after each infusion or after the course. This is the psychological aftercare ASKP3 requires and the integration theme in the literature [source: ASKP3; Drozdz 2022]. No IV protocol opened sets a standard integration format, so the steps below are [synthesis].
Steps [synthesis]:
1. Ask for an open account of the experience, with no pressure to read meaning into it.
2. Separate the drug's perceptual effects from emotional or cognitive material worth working with.
3. Link any insight, change in mood or new perspective to the treatment focus set in preparation. Turn it into one concrete behaviour for the coming week.
4. Check for distress, intrusive images, depersonalisation or shame that lasts beyond the session, and re-check suicide risk.
5. Record mood and risk and send them to the clinic.
Example language (illustrative): "What, if anything, from yesterday feels worth keeping? What would it look like to act on it this week?"
Watch for: Treating every drug image as a deep revelation; ongoing dissociation; quickly building a story around the drug. Ground the work in behaviour and daily functioning.

7. CBT to sustain antidepressant response (Wilkinson protocol)

Purpose / when: Treatment-resistant depression after an initial infusion response. The aim is to keep gains without long-term ketamine maintenance. The 2017 pilot started CBT after the first infusion and ran it alongside and after the course. The 2021 RCT gave 14 weeks of CBT only to responders, after the infusion phase [source: Wilkinson 2021 via study summary; Drozdz 2022].
Steps (the 2021 protocol's structure; wording here is my own):
1. Session frequency: twice weekly for the first two weeks, then weekly, delivered by experienced certified CBT therapists [source: Wilkinson 2021 via study summary].
2. Every session: set an agenda together, review homework, work on the agenda, set new homework [source: same].
3. Early sessions: psychoeducation on the Beck cognitive model of depression and behavioural activation, using activity monitoring and scheduling charts [source: same].
4. Middle sessions: cognitive restructuring with thought records, tackling hopelessness and self-critical beliefs [source: same].
5. Later sessions: relapse-prevention planning for the period after infusions stop [synthesis; the summary did not detail late-phase content].
Example language (illustrative): "The infusions may have lifted the weight a bit. These next weeks are about building the habits and ways of thinking that keep it lifted when the infusions stop."
Watch for: Self-report outcomes (QIDS) favoured CBT, but the clinician-rated primary outcome did not reach significance. Treat this as proof-of-concept, not an established protocol [source: Wilkinson 2021 via study summary]. Sign it is working: activity levels and thought-record skills hold as time since the last infusion grows.

8. Mindfulness-based relapse prevention (MBRP) alongside infusion

Purpose / when: Substance use disorders, tested for cocaine (Dakwar 2019) and alcohol (Grabski 2022) [source: BBRF summary; PPI summary; Drozdz 2022].
Steps:
1. Dakwar 2019 (cocaine, inpatient then outpatient): MBRP started during a short inpatient stay, including a session soon after the infusion, then continued as outpatient MBRP over about five weeks. It taught present-focused awareness and less reactivity to craving and judgements [source: BBRF summary; Drozdz 2022].
2. Grabski 2022 (alcohol, KARE): seven sessions by trained psychologists. Relapse prevention was tailored to the person and combined with mindfulness training, aiming at an enjoyable and meaningful life without alcohol. The control arm had the same number of sessions with the same therapists but only alcohol education (drivers of addiction, alcohol's biological effects, healthy living), with no mindfulness or tailored relapse prevention [source: PPI summary of Grabski 2022].
3. Content per session (standard MBRP structure, not detailed in the summaries opened): brief mindfulness practice, mapping personal high-risk situations, urge-surfing, a short pause-and-notice practice for triggers, and building a valued non-drinking routine [synthesis/uncertain on exact session plan].
Example language (illustrative): "When the craving comes, see if you can notice where it sits in your body and watch it rise and fall, without acting on it or arguing with it."
Watch for: In KARE, ketamine with therapy vs. placebo with education showed the largest difference in days abstinent, but relapse rates did not differ [source: drugsandalcohol.ie record]. Track days abstinent, craving and lapse-to-relapse.

9. Motivational enhancement therapy (MET) alongside infusion

Purpose / when: Alcohol use disorder (Dakwar 2020) and cannabis use disorder (Azhari 2021, proof of concept). The rationale was to use any ketamine-related rise in motivation [source: Drozdz 2022; BBRF summary].
Steps:
1. Dakwar 2020: a five-week outpatient MET course with weekly MET sessions. The infusion was given early in the course, and an extra MET session was added shortly after it [source: Drozdz 2022; BBRF summary].
2. Azhari 2021: MET before, during and after the infusion, with the therapist guiding the participant through the infusion, then MBRP afterwards [source: Drozdz 2022].
3. MET core moves [synthesis, standard MET; not detailed in the sources]: personalised feedback on use, drawing out change talk, building discrepancy between use and values, supporting self-efficacy, a change plan.
Example language (illustrative): "You mentioned feeling clearer since the infusion. What does that clearer part of you want to do about drinking?"
Watch for: Abstinence, delay to relapse and fewer heavy-drinking days were the trial outcomes; ketamine also seemed to help stop a lapse becoming a relapse or drop-out [source: BBRF summary].

10. Exposure-based therapy positioned around infusions (OCD, PTSD)

Purpose / when: OCD (Rodriguez 2016: a CBT session before the infusion, exposure work afterwards) and PTSD (Shiroma 2020: prolonged exposure sessions positioned shortly after infusions; Duek 2019 abstract: infusion after the first of a series of daily PE sessions) [source: Drozdz 2022]. Choose the timing with the prescriber.
Steps:
1. Run the standard ERP or prolonged-exposure protocol (hierarchy, in-vivo and imaginal exposure, processing) as its own manual requires. Ketamine changes the timing, not the content [source: Drozdz 2022 for timing; content per the parent protocols].
2. Agree with the clinic the sequence of exposure sessions and infusions.
3. Do not start exposure while the client is still under acute drug effects or before discharge criteria are met [synthesis].
Safety and consent: Get specific consent for exposure. Check stabilisation, current dissociation level, suicide risk and the client's ability to tolerate distress. Have a plan to stop or step down if distress or dissociation goes beyond the window of tolerance [synthesis; standard exposure practice].
Example language (illustrative): "Today we'll go back to the memory as we planned. You stay in charge of the pace, and we'll stop and ground whenever you need."
Watch for: Within- and between-session reduction in distress on the parent protocol's measures (e.g. SUDS, PCL-5, Y-BOCS, used under licence without reproducing items).

11. TIMBER (Trauma Interventions using Mindfulness-Based Extinction and Reconsolidation)

Purpose / when: Chronic PTSD, developed by Pradhan and colleagues. It is a mindfulness-based CBT aimed at trauma memories, combining graded exposure with reconsolidation strategies while avoiding re-traumatisation [source: Pradhan et al. 2017 via study summary]. Pilot evidence only (n = 10).
Steps (paraphrased from the paper summary):
1. Personalise using a mindfulness-interventions assessment scale and a scripted narrative of the index trauma.
2. Core component: mindfulness-based graded exposure therapy (MB-GET).
3. Around the infusion, the therapist guides a brief, controlled reactivation of the trauma memory, followed straight away by de-escalation and mindful, detached monitoring (a short 'mini-TIMBER' module, run in cycles).
4. The client practises a short mini-TIMBER routine at home. If symptoms return, full weekly TIMBER sessions of about 40–45 minutes follow [source: same; the paper is internally inconsistent on session numbers, see uncertain].
Example language (illustrative): "Bring the memory up for just a moment, then step back and watch it as if from a riverbank: thoughts, sensations, letting them pass."
Watch for: Distress that does not settle after reactivation (stop, ground). [uncertain]: session counts and follow-up periods are inconsistent within the paper. Ketamine-plus-TIMBER and saline-plus-TIMBER did not differ significantly in the randomised comparison.

12. In-session presence (only where the clinic protocol includes a therapist)

Purpose / when: Some trial protocols had therapists guide participants through the infusion (Dakwar 2019, Azhari 2021) or work at the bedside (Keizer 2020, inpatient). Most IV studies did not describe what therapists did, or the music, eyeshades or room set-up [source: Drozdz 2022]. A licensed medical provider must be present during administration, and medical staff are responsible for monitoring [source: ASKP3 via Osmind; Sanacora 2017].
Steps [synthesis]:
1. Attend only under a written clinic protocol that defines your role. Medical staff hold all monitoring and stopping decisions.
2. Keep contact brief, calm and non-directive unless a structured protocol (e.g. TIMBER, MET) says otherwise.
3. Ask the client before any touch. Agree touch rules in preparation; supportive touch is limited to hand or shoulder with prior consent [synthesis; no IV-clinic touch policy found, uncertain].
4. Tell staff at once about anything that looks medical or behavioural (agitation, confusion, marked distress).
Example language (illustrative): "I'm here. You're safe, and the staff are watching over you. You don't need to do anything."
Watch for: Being drawn into deep processing during peak effects. Leave it for integration.

13. Suicide-risk monitoring and safety planning across the course

Purpose / when: At every contact. Many clients are referred because of suicidality, and relief can fade. An on-site clinician must assess suicidal ideation before discharge, and rapid psychiatric follow-up must be available [source: Sanacora 2017]. Esketamine carries the antidepressant-class suicidality warning and is not a substitute for hospitalisation [source: FDA label].
Steps:
1. Use a structured risk assessment at each session. Update the written safety plan (warning signs, coping steps, contacts, crisis numbers, lethal-means storage and removal) [synthesis; standard practice].
2. Pay extra attention after an infusion response fades and around the end of the course [synthesis].
3. Arrange hospital-level care if needed. Do not wait for the next infusion [source: FDA label].
4. Pass any change to the prescriber the same day.
Example language (illustrative): "Sometimes the lift fades between infusions, and that drop can be harder than before. If that happens, what's the first thing on your plan?"
Watch for: Hopelessness tied to the infusion ('if this fails, nothing will work'). Name it and plan for it in advance.

14. Screening and responding to ketamine misuse

Purpose / when: Throughout. Ketamine has abuse potential, and misuse has been reported in depression treatment [source: Sanacora 2017; FDA label].
Steps:
1. Ask routinely about non-clinic ketamine or other dissociatives, and about treatment at other centres [source: Sanacora 2017].
2. Watch for craving for the infusion experience, demands for more frequent sessions, and new cognitive or urinary symptoms [source: Sanacora 2017; RANZCP 2022].
3. If misuse is suspected, tell the prescriber, who may use intermittent urine toxicology [source: Sanacora 2017], and treat the substance use as its own problem.
Example language (illustrative): "Some people find they want the feeling, not just the mood lift. Is any of that true for you?"
Watch for: Secrecy, buying ketamine online or on the street, or using home 'top-ups'. Unsupervised self-administration goes against the consensus standards [source: Sanacora 2017; ASKP3 via Osmind].

15. Taper, discontinuation and relapse-prevention planning

Purpose / when: From the start of treatment and again as the course nears its end. The APA statement says treatment should aim at eventual taper and discontinuation [source: Sanacora 2017]. Wilkinson's trial was designed as a way to keep gains without ongoing ketamine [source: Wilkinson 2021 via summary].
Steps [synthesis]:
1. Agree early with client and prescriber that stopping or spacing infusions is the goal.
2. Build a written relapse-signature and action plan: early signs, coping skills from CBT/MBRP, when to re-contact the clinic.
3. Keep therapy going through and beyond the last infusion.
Example language (illustrative): "Let's plan now for life after the infusions, so that ending them feels like a step forward, not losing a lifeline."
Watch for: Fear of ending treated as a reason to keep infusing. Work with that fear directly.

16. Harm-reduction and integration support for people using ketamine outside clinics

Purpose / when: A client uses ketamine unsupervised, through a home programme, or from illicit sources. The clinician's role is harm reduction and integration, never facilitation [Sanacora 2017; ASKP3 via Osmind].
Steps [synthesis]:
1. Assess the pattern of use, mental-state effects, cognition, urinary symptoms, risk and mixing with alcohol or sedatives (in general terms).
2. Explain in general terms the risks the sources name: dependence, bladder and cognitive harm, impaired driving, and danger when mixed with other depressants. Give no dosing information.
3. Make a safety plan: never alone, no driving, no mixing with other substances.
4. Offer referral to a supervised, regulated service or to addiction treatment, and keep integration support going.
Example language (illustrative): "I won't advise on how to use it, but I can help you think through the risks and what would make you safer, and talk about getting this supervised properly."
Watch for: Escalating use and worsening mood between uses.

5. Handling problems

The sources mostly set safety duties. They say little about clinical difficulties in therapy, so most responses below are [synthesis] unless tagged.

Acute distress or dissociation during or right after an infusion. Medical staff manage acute dissociative or psychotomimetic states and behavioural emergencies, and the clinic must have plans for these [source: Sanacora 2017]. Your part: use the grounding plan you agreed, then process the experience in an early integration session. Look for lasting depersonalisation and refer back to the prescriber if it continues [synthesis].
Frightening or traumatic content in the experience. Normalise it, avoid reading it as revelation, and link it to the trauma formulation only at the client's pace. If it looks like traumatic re-experiencing, move to stabilisation before any exposure work [synthesis].
Rapid relief followed by relapse (the 'cliff'). Expect this. Most data cover less than a month [source: Sanacora 2017]. Respond with the relapse-prevention plan (item 15), more frequent therapy contact for a while, risk re-assessment, and a joint review with the prescriber [synthesis].
Non-response. No response after an adequate course may mean further treatment is futile [source: Sanacora 2017]. Help the client grieve the hope they invested, re-assess, and re-plan with the team (other treatments, intensified psychotherapy) [synthesis].
Client wants more infusions, or more often. The consensus advises the fewest needed for response and says frequent infusions are not supported by evidence [source: Sanacora 2017]. Explore what is driving the request (craving, avoidance, fear of relapse) and raise it with the prescriber. Possible misuse: item 14.
Low engagement with therapy ('the drug is doing the work'). Revisit the 'treatment, not a cure' framing [source: ASKP3]. Show the score graph. Present structured therapy as the way to keep gains after infusions stop, which is the rationale of the Wilkinson trial [source: Wilkinson 2021 via summary]. Make homework smaller [synthesis].
Non-adherence to safety rules (driving, alcohol, going home alone). Treat it as a risk issue. Problem-solve transport and tell the clinic, which owns discharge rules [source: Sanacora 2017; FDA label; synthesis].
Rupture over the client's use of a clinic you have doubts about. Raise your concerns using published standards (psychiatric evaluation, monitoring, aftercare, outcome tracking) rather than personal opinion [source: ASKP3]. Stay open to keeping integration support going. Say plainly what you can and cannot recommend [synthesis].
Splitting between therapist and clinic. Prevent it with the joint-working agreement (item 2). When conflicting messages arise, hold a joint conversation with the client present where possible [synthesis].
Emerging misuse or ketamine use disorder. See item 14. Shift the focus to substance-use treatment and coordinate with the prescriber on whether to continue [source: Sanacora 2017; synthesis].
Cognitive or bladder symptoms. Treat them as medical. Refer straight to the prescriber; these are monitored outcomes with repeated treatment [source: Sanacora 2017; RANZCP 2022; FDA label].
Mania, hypomania or psychotic symptoms after infusion. Refer to the prescriber or crisis services the same day. Psychotic disorders and history are assessed before treatment [source: Sanacora 2017; synthesis on response].
Pregnancy or breastfeeding. Esketamine should not be used in pregnancy, and breastfeeding is not advised during treatment [source: FDA label]. Send any pregnancy disclosure to the prescriber at once [synthesis].
Rising suicide risk between infusions. Follow item 13. Arrange urgent assessment; infusions do not replace hospital care [source: FDA label; Sanacora 2017].
Unrealistic or spiritualised expectations. Some clients bring psychedelic-model stories of transformation. Acknowledge their meaning, keep the work focused on goals and function, and present such frameworks as one view among others [source: Drozdz 2022 on psychedelic vs non-psychedelic models; synthesis].
Cost and access. Off-label infusions are often self-funded [uncertain; cost listed as a consent topic by RANZCP 2022]. Discuss the financial strain and its effect on hope and pressure, and do not let cost decide clinical choices [synthesis].

Sources

Sources:

Further reading (not drawn on): papers cited through the review or summaries: Wilkinson ST et al. 2017, Psychother Psychosom; Wilkinson ST et al. 2021, Psychother Psychosom; Dakwar E et al. 2019, Am J Psychiatry (cocaine, MBRP); Dakwar E et al. 2020, Am J Psychiatry (alcohol, MET); Grabski M et al. 2022, Am J Psychiatry; Pradhan BK et al. 2017, Asia Pac J Clin Trials Nerv Syst Dis; Rodriguez CI et al. 2016, J Clin Psychiatry; Shiroma PR et al. 2020, J Clin Psychiatry; Azhari N et al. 2021, Am J Drug Alcohol Abuse; Keizer BM et al. 2020, Psychother Psychosom; McInnes LA et al. 2026, J Affect Disord 411:121970.

Further reading (not drawn on): ASKP3 full standards page and the AJP full text of Grabski 2022. Exact MBRP and MET session plans used with infusions, and UK, Canadian and EU regulatory status of racemic ketamine clinics, are [uncertain].

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