The first step of any psychedelic-assisted therapy process is to assess for eligibility (Hull et al., 2022). Clients must be screened for high blood pressure, schizophrenia, pregnancy/desire to become pregnant or impregnate another, and other cardiac, neurological, and psychological contraindications. Clients must also consent to refraining from alcohol, stimulants, benzodiazepines, and other contraindicated drugs for 24 hours before and after treatment, refrain from driving or operating machinery the day of treatment, and fast from food for 3 hours prior to treatment. Finally, clients must understand that ketamine is a mind-altering substance that will result in feelings of dissociation and ineffable dream-like experiences, as well as possible dizziness, nausea, and loss of sensation in the body.

The above should be briefly assessed by the client’s therapist to rule out clear ineligibilities before referring the client to a licensed doctor, physician’s assistant, or psychiatric nurse practitioner to conduct a more thorough, 45–60-minute assessment and informed consent process. Eligible clients will be prescribed rapidly dissolving ketamine tablets (RDTs) that are sent directly to the client’s home from a compounding pharmacy. Clients will also be prescribed 4mg ondansetron (Zofran) to be taken twenty minutes prior to the ketamine session to reduce nausea. Most KAP treatments consist of four ketamine sessions, each spaced one week apart; however, each client’s treatment plan will be created on a case by case basis.

Once a client is prescribed the ketamine ODTs, they must meet with their therapist to set an intention for their first ketamine session (Hull et al., 2022). Intentions usually take the form of a command, beginning with a phrase like show me or teach me, such as teach me how to accept my trauma or show me my relationship with my mother. It is important to understand that the ketamine experience, like the experience of dreaming, is often wild, tangential, strange, and difficult to control; however, like dreaming, the content of a ketamine experience can be informed by the material one thinks about prior to the session. Intentions are akin to the “movie” a client watches before bed—they are the door through which a client chooses to enter the otherwise amorphous ketamine space, and they color the overall quality of the session.

Psychoeducation is important at this stage of treatment, as clients may have a clear understanding of where they would like to explore psychologically, but they may fear doing so. For this reason, it can be valuable to explain to clients in simple terms that ketamine works by suppressing fight-or-flight response and increasing overall creativity and plasticity in the brain. Therefore, traumas that may otherwise be too triggering or difficult to address under sober conditions can be processed on ketamine without stirring up their usual trauma responses. This does not mean that challenging experiences do not occur, and clients should never be pushed beyond their comfort zone, but it is exceedingly likely that the client’s comfort zone will expand greatly while on ketamine.

Client and therapist should work together to find an initial intention that acclimates the client to the work ahead, which is why show me what it feels like to be in the ketamine space is, in my experience, the most common first intention. Once a client feels safe and comfortable going through their first treatment, more specific intentions will likely be set to address their trauma more directly. Clients can also choose to set a macro-intention that will stay constant throughout the entire course of treatment and is unlikely to resolve in a single session. An example macro-intention is show me how to overcome my depression and anxiety.

The client and therapist should meet at a later date, in person, to administer the ketamine. The client should also plan to be picked up by a trusted friend or loved one on the day of treatment. The therapist should provide an eye mask, pillows and blankets, a comfortable space to lie down, and quality headphones to play pre-selected music to aid the ketamine experience. Client and therapist will discuss any anxieties that arise prior to taking the ketamine, and clients will be reminded that it is not too late to revoke consent! The therapist will confirm that the client has abstained from alcohol, benzodiazepines, stimulants, and other contraindicated or illicit drugs for 24 hours, and has fasted for 3 hours. Client and therapist will review the client’s intentions, although it should be elucidated that the ketamine session is a time for experiencing, not necessarily for processing, so there is no need to make sense of anything that arises; processing will be done at a later date, during the Integration Session. Finally, the client will be instructed to urinate (as ketamine is a diuretic and is best taken on an empty bladder), and treatment will begin (Hull et al., 2022).

The client will be instructed to lie down in a comfortable position, seated upright, with their head tilted forward. The client will place the RDT under their tongue and it will quickly dissolve into a pool of saliva that the client will hold in their mouth for 20 minutes. The therapist will lead the client through a 20-minute guided meditation as approximately 10-20% of the ketamine is absorbed through the cheeks, and the client will be instructed to swallow the liquid once time has commenced. At this time, the client should already feel the initial sublingual effects of the ketamine, although a stronger wave of dissociation will come in 20-45 minutes when the ketamine is reabsorbed in the stomach. The client will lie down fully with their eye mask on and music playing, and will continue to do so until the experience ends in 1-3 hours. The therapist and/or a trained assistant will be available during the full length of treatment, should the client need assistance processing challenging content that emerges. However, it is rare that clients choose to talk during ketamine sessions, and often do not possess the faculties to engage in a coherent therapeutic dialogue. The treatment ends when the client no longer is experiencing visual hallucinations dissociation, and somatic feelings have returned to the body. Dizziness or wooziness is normal, although clients should be given a comfortable place to rest until they can safely walk out of the office without stumbling. Clients should also be encouraged to rest for the remainder of the day, and should be given a journal to document what they experienced.

Client and therapist should meet within the week to discuss the content of the session. The Integration Session should be a 45-minute psychotherapy session, although the focus of the session should be on making sense of the ketamine experience. The therapist should, at minimum, ask the following questions:

1) What did you see?

2) What did you feel (somatically)?

3) What did you feel (emotionally)? and

4) How are you making sense of the session now/what is staying with you?

After the integration session, the client should meet once more with their ketamine prescriber to reassess dosage and discuss any other medical questions outside the therapist’s scope of practice. The client will then be prescribed 3 more sessions worth of ketamine, and will repeat the process: intention, ketamine session, integration.