What Therapists Should Know Before Referring a Client for Ketamine-Assisted Psychotherapy

More clients are asking about ketamine. They have seen the headlines, heard a friend’s story, listened to a podcast, or come across a clinic promising rapid relief from depression or anxiety. Increasingly, they are bringing the question into therapy and asking: What do you think?

If you are a therapist, you do not need to become an expert in ketamine or psychedelic medicine to have that conversation. But I do think it helps to understand what ketamine-assisted psychotherapy (KAP) actually is, where the evidence is strong and where it is still developing, who may or may not be appropriate for it, and what a thoughtful referral should look like.

It is also important to separate being informed about KAP from actually providing it. In my practice, therapists who participate in the ketamine medicine sessions have specific training in ketamine-assisted psychotherapy. A client’s regular therapist does not necessarily need that training. In fact, I often prefer that clients stay with therapists who already know them well and continue the longer-term work there.

What KAP Actually Is

Ketamine-assisted psychotherapy pairs ketamine with psychotherapy. Ketamine works primarily through the glutamate system and has downstream effects associated with synaptic plasticity. There is good evidence that ketamine itself can produce rapid antidepressant effects, particularly in treatment-resistant depression.

The psychotherapy part is a little more complicated.

The idea behind KAP is that ketamine may create a period in which thoughts, emotions, memories, or habitual ways of seeing things feel somewhat less fixed. Some clients describe being able to look at painful material with more distance. Others notice connections they have not made before or experience emotions that have been difficult to access in ordinary therapy.

And some people simply feel strange, sleepy, nauseated, disconnected, or not particularly transformed.

That is important to say because ketamine has acquired a mythology around it. Not every session is profound. Not everyone has a psychedelic experience. A more intense experience does not necessarily mean a better clinical response.

I tend to think of ketamine as potentially creating an opening. The therapeutic question is what happens with that opening afterward.

There is a scientific caveat here that I think is worth being honest about. We have considerably stronger evidence for ketamine as a treatment for depression than we do for KAP as a specific combined treatment. Pairing ketamine with psychotherapy makes clinical sense to me, and it is the model I prefer, but research has not yet established that adding psychotherapy reliably improves ketamine’s antidepressant effect. KAP is also not one standardized protocol. Dose, route, preparation, therapy during the medicine session, and integration can look very different from one practice to another.

That does not make KAP unscientific. It means we should be careful not to present a promising clinical model as more settled than it actually is.

Ketamine, KAP, and Spravato Are Not the Same Thing

This is an area where patients understandably get confused, because the terms are often used as though they mean the same thing.

Traditional ketamine, the medication used for decades as an anesthetic, contains two molecular forms of ketamine. This is sometimes called racemic ketamine. Its use for psychiatric conditions is off-label, although it has been studied extensively for treatment-resistant depression. In psychiatric settings, ketamine is most commonly given by IV infusion, but other routes are also used.

Ketamine treatment does not necessarily involve therapy. Some clinics provide ketamine primarily as a medical treatment for depression, with monitoring before, during, and after the medication.

Spravato is the brand name for intranasal esketamine, which contains one of the two molecular forms found in traditional ketamine. Unlike traditional ketamine, Spravato has specific FDA-approved indications for depression and must be administered in a certified healthcare setting with required monitoring afterward.

KAP, or Ketamine-Assisted Psychotherapy, is not a different drug. It is a treatment model. Ketamine is used intentionally as part of psychotherapy, typically with preparation beforehand, a supported medicine session, and integration afterward. The goal is not simply to see whether ketamine improves depressive symptoms but to use the experience as part of the therapeutic work.

So, someone receiving IV ketamine for depression is receiving ketamine treatment, but not necessarily KAP. Someone receiving Spravato is receiving esketamine treatment, not KAP. Someone doing KAP is receiving ketamine within a psychotherapy framework.

All three can have a legitimate place in psychiatric care. They overlap, but they are not interchangeable.

Training Matters

A therapist does not need KAP training simply to talk with a client about ketamine or suggest that they get an evaluation.

Actually sitting with and treating someone while they are under the effects of ketamine is different.

Someone can become very dissociated. Their sense of time and body may change. They may become frightened or confused. Trauma material can emerge. Someone who is normally very verbal may suddenly not want to talk at all.

The therapist needs to know when to engage and when to stay quiet, how to help someone who becomes frightened without unnecessarily pulling them out of the experience, how to work with dissociation, and how to avoid imposing meaning on something the client is still trying to understand.

Traditional psychotherapy training does not necessarily prepare someone for that.

For that reason, in my practice I only provide KAP in collaboration with therapists who have specific training in ketamine-assisted psychotherapy.

That is my practice standard. There is not one universally standardized KAP certification or psychotherapy protocol at this point, which is another reason I think therapists should ask questions about someone’s actual training rather than simply seeing the words “ketamine-assisted therapy” on a website.

Your Client Can Still Remain Your Client

I think this is particularly important for therapists to know.

A referral for KAP does not have to mean transferring your client’s therapy to someone else.

Sometimes the client’s existing therapist is KAP-trained and participates throughout the process. Other times, a KAP-trained therapist joins the treatment specifically for preparation and medicine sessions while the client continues seeing their regular therapist.

Afterward, integration can happen with the KAP therapist, the ongoing therapist, or both.

I actually like this model.

The client’s regular therapist often knows much more about them than anyone joining the treatment for a handful of ketamine sessions ever will. You know their relationships, defenses, patterns, history, avoidance, strengths, and the things they have been circling around for the past two years.

If something important comes up during ketamine, that existing therapeutic relationship can be an excellent place to work with it.

The ongoing therapist does not necessarily need formal KAP training to do that. They should understand enough about ketamine to make sense of the experience with the client and feel comfortable discussing what came up.

With the client’s permission, communication between the prescriber, KAP therapist, and ongoing therapist can also be very helpful. I prefer this to having three clinicians treating the same person without knowing what anyone else is doing.

Different Roles, One Treatment Team

The prescriber’s role is primarily medical. I evaluate the client’s psychiatric history, current symptoms, medications, substance use, relevant medical conditions, and potential contraindications. I determine whether ketamine is appropriate and manage the prescribing, dosing, and medical aspects of treatment.

The KAP therapist’s role is different. They help prepare the client for the experience, talk through expectations and intentions, provide therapeutic support surrounding the medicine session, and help the client begin processing what occurred.

The client’s regular therapist may then continue the longer-term psychotherapy and integration.

Sometimes one therapist fills both therapeutic roles. Sometimes there are three clinicians involved.

I am less concerned about exactly how the team is arranged than I am about whether everyone knows what their job is and whether there is communication when it matters.

Who Tends to Do Well, and Who Doesn't

Careful screening is one of the most important parts of the process, and the medical screening belongs to the prescriber.

Still, it helps therapists to understand generally what we are looking for.

Clients who tend to be better candidates are medically and psychiatrically stable enough to participate safely, have some capacity for introspection and emotional regulation, can engage in preparation and follow-up work, and have realistic expectations about what ketamine may and may not do.

Certain situations may exclude someone from treatment or require additional evaluation and caution. These can include:

• Active psychosis or a psychotic disorder

• Active mania or unstable bipolar disorder

• Uncontrolled hypertension or significant cardiovascular disease

• Active or poorly controlled substance use disorder, particularly when there is concern about misuse of ketamine or other dissociatives

• Pregnancy

• Certain significant medical conditions that may affect the safety of ketamine treatment

Acute safety concerns also require careful assessment. Ketamine has evidence for rapidly reducing suicidal ideation in some patients, but outpatient KAP is not a substitute for a higher level of care when someone cannot be safely managed in an outpatient setting.

This list is intentionally broad and is not exhaustive. It is also not meant to turn therapists into medical screeners. That is the prescriber’s job.

The therapist’s role is to understand enough to recognize concerns, have an informed conversation, and know when a specialized evaluation is appropriate.

What About Someone Who Is Suicidal?

This deserves its own discussion because ketamine is often described as a treatment for suicidality.

There is evidence that ketamine can rapidly reduce suicidal ideation in some patients, and that can be clinically very meaningful. But reducing suicidal thoughts is not the same thing as demonstrating that ketamine prevents suicide.

Someone who is acutely suicidal still needs a complete safety assessment. If they need hospitalization or another higher level of care, an outpatient ketamine appointment is not a substitute for that.

I would be especially uncomfortable with the idea of sending a clinically unstable patient home with ketamine simply because ketamine has been associated with rapid improvement in suicidal ideation.

The Expectations Conversation

This is probably one of the most important parts of the evaluation for me.

By the time people reach my office asking about ketamine, they have often already heard a success story.

Sometimes they have been depressed for years and have tried multiple medications and years of therapy. They are exhausted and understandably want something to finally work.

Other times, I notice a different pattern. The person has been moving from one treatment to the next: a medication, a supplement, a new kind of therapy, a peptide, something they heard about on a podcast. Now ketamine is next.

I am open to many of these treatments. That does not mean I assume the newest or most interesting treatment is automatically the right one.

So I usually want to know: What are we actually trying to treat? What have you tried? What helped? What didn’t? What is happening in therapy right now? And, maybe most importantly, what do you imagine ketamine is going to change?

If someone believes one ketamine experience is going to erase years of depression, trauma, anxiety, or entrenched relationship patterns, we should talk about that before starting.

Ketamine can sometimes work remarkably quickly. The effect may also fade. Some people respond very well, some partially, and some not at all.

It also does not have to replace everything else.

Someone can take Lexapro and do ketamine. They can take medication and use supplements. They can work on sleep, exercise, hormones, nutrition, relationships, and trauma while also taking an antidepressant.

I practice integrative psychiatry because I am interested in all of those pieces, not because I think conventional psychiatric treatment needs to be discarded in order to make room for newer approaches.

A Harm-Reduction Approach to Ketamine

I take a similar approach when patients ask me about psychedelics, supplements, peptides, cannabis, or treatments they have found online.

People are going to explore things.

I would rather they tell me.

If someone is thinking about ketamine, I want to know what they are considering, where they are getting it, what else they are taking, what they expect from it, and whether there are ways to make what they are doing safer.

That does not mean I endorse everything someone wants to try. Sometimes my answer is that I don’t think something is a good idea. But I want patients to be able to tell me the truth without worrying that mentioning a psychedelic or an unconventional treatment is going to end the conversation.

I think therapists can create the same kind of space.

Questions I Would Ask Before Referring

If you are considering referring a client for KAP, I would want to know:

• Who is doing the psychiatric and medical evaluation?

• Who is prescribing the ketamine?

• What training does the therapist participating in the medicine session have?

• What preparation happens beforehand?

• Is someone with the client during the ketamine experience?

• What happens if the client becomes frightened, very dissociated, or medically unwell?

• What is the plan for integration?

• Can the client continue with their existing therapist?

• Is the treatment team willing to communicate with the client’s therapist, with appropriate consent?

• What happens if there is a psychiatric or medical concern between sessions?

Access to ketamine has become relatively easy in some settings. That is not necessarily the same thing as having a thoughtful treatment plan.

A Few Common Questions

Do I need to be KAP-trained to refer a client?

No. I think therapists should know enough to have an informed conversation, but you do not need specialized training simply to recognize that someone might benefit from an evaluation.

Can a therapist prescribe ketamine?

No, unless that therapist also independently holds a license with prescribing authority. Ketamine is a prescription medication. The medical evaluation and prescribing need to be handled by an appropriately licensed prescriber.

Does the client’s regular therapist have to participate in the ketamine session?

No. A KAP-trained therapist can work specifically around the ketamine sessions while the client remains in treatment with their existing therapist.

Is KAP appropriate during an acute psychiatric crisis?

Usually that is not where I start. Someone who is acutely unstable needs an assessment of what level of care is actually appropriate. Ketamine has interesting evidence around rapid improvement in depression and suicidal ideation, but that does not make outpatient KAP a replacement for crisis care.

Is KAP better than IV ketamine without psychotherapy?

We don’t know.

There is good evidence for ketamine’s antidepressant effects. The evidence that adding psychotherapy produces a superior antidepressant response is much less established. I prefer incorporating psychotherapy because I am interested in what happens beyond symptom reduction and because many of the patients I see are dealing with longstanding patterns, trauma, relationships, or ways of understanding themselves in addition to depression.

But that is different from claiming the research has proven KAP is superior.

Where I Land

I am interested in ketamine. I use it in my practice, and I think it can be very helpful for the right person.

I am also cautious about the way treatments like this can become idealized.

Psychiatry has gone through many periods when a treatment was either embraced as the answer or dismissed because it did not fit comfortably into the existing model. Neither approach is particularly useful to me.

I don’t think patients should have to choose between being “holistic” and taking psychiatric medication. I also don’t think being evidence-based requires us to ignore treatments simply because the research is newer or the treatment looks different from what we were doing ten years ago.

Sometimes I recommend ketamine. Sometimes I recommend changing an antidepressant. Sometimes I think we should leave the medication completely alone and look more closely at sleep, hormones, alcohol, nutrition, ADHD, relationships, or what is happening in therapy.

And sometimes someone comes in very excited about ketamine and I tell them I don’t think they need it.

That is part of the evaluation too.

For me, the point is not to get someone onto ketamine. It is to understand what is actually going on and decide whether ketamine has a useful place in their treatment.

When it does, I want it done thoughtfully, with appropriate medical screening, a therapist who understands altered states, realistic expectations, and communication with the people already treating the client.

Ketamine can sometimes loosen something that has felt very stuck. What happens next still matters.

This article is for educational purposes only and should not be considered medical advice. Ketamine is not appropriate for everyone. Individual treatment decisions should be made after evaluation by qualified medical and mental health professionals.