Harper Clinic Utah Ketamine-Integrated Psychotherapy · Therapist Training

harperclinicutah.com · (801) 396-9496 Version 1.0 · For Internal Clinical Use

Integrative Psychiatry · Utah

Ketamine-Integrated Psychotherapy (KAP)

Comprehensive Self-Guided Training Program

Intended Audience: Licensed mental health professionals with experience in trauma and psychotherapy
Goal: Develop full clinical competency in Ketamine-Integrated Psychotherapy (KAP)
Format: Self-guided with supervised practicum component

Important Notice

This training program is designed to supplement — not replace — supervision, mentorship, and where applicable, formal certification through recognized KAP training organizations. All clinical practice must occur within the scope of your licensure and in collaboration with a licensed prescribing provider.

Program Overview

Training Modules

Module	Title
1	Foundations of Ketamine & KAP
2	Trauma-Informed Care in KAP
3	Non-Ordinary States of Consciousness
4	Target Populations & Clinical Assessment
5	Personal Psychotherapy & Experiential Preparation
6	Core KAP Clinical Skills: Preparation Phase
7	Core KAP Clinical Skills: Medicine Session
8	Core KAP Clinical Skills: Integration Phase
9	Ethics, Safety & Boundaries
10	Supervised Practicum & Competency Evaluation

Module Training Hours

1–2 hours

to read all 10 modules

Recommended Practicum Hours

Minimum 40–60

supervised hours

Module 1

Foundations of Ketamine & KAP

Learning Objectives

By the end of this module, you will be able to:

Explain ketamine's pharmacology and mechanisms of action relevant to psychiatric treatment
Describe the neurobiological basis for combining ketamine with psychotherapy
Distinguish KAP from standalone ketamine infusion therapy
Understand the legal and regulatory context of ketamine practice

Section 1.1: Ketamine Pharmacology

What is Ketamine?

Ketamine is a dissociative anesthetic first synthesized in 1962 and approved by the FDA in 1970 for anesthetic use. It is a Schedule III controlled substance, making it legally prescribable off-label by licensed providers. It exists in two forms:

Racemic ketamine — the original form, used IV, IM, or orally (off-label for psychiatry)
Esketamine (Spravato) — the S-enantiomer, FDA-approved (2019) for Treatment-Resistant Depression and MDD with acute suicidal ideation, administered intranasally in certified healthcare settings

Primary Mechanisms of Action

NMDA Receptor Antagonism — Ketamine blocks N-methyl-D-aspartate glutamate receptors, disrupting excitatory neurotransmission and creating the dissociative state
AMPA Receptor Potentiation — Downstream activation of AMPA receptors triggers BDNF (Brain-Derived Neurotrophic Factor) release
Neuroplasticity Induction — BDNF upregulation stimulates synaptogenesis, essentially creating a window of enhanced neural rewiring (typically 2–4 weeks post-administration)
Default Mode Network (DMN) Disruption — Ketamine reduces rigid, ruminative DMN activity, potentially allowing new perspectives and psychological flexibility
Opioid Receptor Activity — Some antidepressant effect may involve opioid pathways (an area of active research)
Monoamine Effects — Secondary effects on dopamine and serotonin systems contribute to mood elevation

Routes of Administration Relevant to KAP

IV infusion — Most studied; precise dosing; requires medical setting; 40–60 min session
IM injection — Slightly less predictable; often used in KAP settings; 45–60 min
Oral/sublingual (troches) — Lower bioavailability (~20–30%); gentler experience; increasingly used in outpatient KAP
Intranasal (Spravato) — FDA-approved; administered in certified clinical settings

Dosing Ranges Relevant to Therapists

Dosing is the prescriber's responsibility. Therapists should understand ranges for psychoeducation purposes.

Sub-anesthetic psychiatric doses: typically 0.5 mg/kg IV over 40 minutes
IM: 0.5–1.5 mg/kg
Oral/sublingual troches: 200–600 mg (variable absorption)
Psychedelic/dissociative experiences occur at the higher end of these ranges

Section 1.2: The Neuroplasticity Window — Why Psychotherapy Matters

The most critical concept for the KAP therapist is understanding the neuroplasticity window: Following ketamine administration, there is a period — estimated at 2–4 weeks — during which the brain demonstrates heightened synaptic plasticity, new dendritic spine formation, and increased psychological flexibility. This is the therapeutic target.

Without psychotherapy, this window closes and the brain can return to prior rigid patterns. The antidepressant effect alone may last weeks to months, but sustainable psychological change requires that something therapeutically meaningful happens during this window.

With KAP, the therapist works actively within this window to:

Help the patient process and integrate insights from the medicine session
Introduce new behavioral patterns while the brain is most receptive
Address underlying trauma, maladaptive schemas, or relational patterns
Build psychological skills (distress tolerance, emotional regulation, cognitive flexibility)

This is the core rationale for KAP over ketamine infusion alone.

Section 1.3: KAP vs. Ketamine Infusion Therapy

Feature	Ketamine Infusion	KAP
Goal	Symptom reduction	Symptom reduction + psychological transformation
Therapist involvement	Minimal or none	Central
Preparation	Medical screening only	Therapeutic preparation sessions
During session	Medical monitoring	Therapeutic presence + facilitation
After session	Discharge instructions	Active integration therapy
Neuroplasticity window	Passive	Actively utilized
Durability	Weeks to months	Potentially longer-lasting

Section 1.4: Legal & Regulatory Framework

Current Legal Status

Racemic ketamine is legal for off-label psychiatric use when prescribed by a licensed MD/DO/NP/PA
The KAP therapist operates under their own mental health license
A collaborative care agreement with the prescribing provider is strongly recommended
Therapists do not administer ketamine — this is always the prescriber's role
Spravato must be administered in a certified REMS (Risk Evaluation and Mitigation Strategy) program

Practice Models

Integrated clinic — prescriber and therapist work in the same practice (your likely model)
Collaborative model — therapist refers to/from a ketamine clinic
Therapist-led with prescriber partner — therapist holds the therapeutic relationship; prescriber manages the medicine

Documentation Requirements

Separate informed consent for KAP
Session notes for preparation, medicine, and integration sessions
Communication logs between therapist and prescriber
Adverse event documentation protocol

Module 1 Readings & Resources

Dore, J. et al. (2019). "Ketamine Assisted Psychotherapy: A Systematic Narrative Review of the Literature." Journal of Psychoactive Drugs
Wolfson, P. & Hartelius, G. (Eds.). The Ketamine Papers. MAPS Press.
Phelps, J. (2017). "Developing Guidelines and Competencies for the Training of Psychedelic Therapists." Journal of Humanistic Psychology
ASKP3 Clinical Practice Guidelines (available at askp3.org)

Module 1 Self-Assessment

I can explain ketamine's mechanism of action to a patient in plain language I understand why the neuroplasticity window makes psychotherapy essential I can describe the difference between KAP and infusion-only therapy I am familiar with the legal scope of my role as a KAP therapist I understand the different routes of administration and their clinical implications

Module 2

Trauma-Informed Care in KAP

Learning Objectives

Apply trauma-informed principles specifically within the KAP context
Understand how ketamine interacts with trauma-stored somatic and psychological material
Identify when trauma history requires modified KAP approach
Recognize and manage trauma activation during medicine sessions

Section 2.1: Why Trauma-Informed Care is Non-Negotiable in KAP

Ketamine's dissociative properties and DMN disruption can lower psychological defenses that ordinarily keep traumatic material contained. This means:

Patients may unexpectedly access trauma memories during sessions
The altered state can feel frightening or destabilizing to trauma survivors
Re-traumatization is a real risk if the therapist is not prepared
Conversely, the altered state can provide a unique therapeutic window for trauma processing when carefully facilitated

The KAP therapist must therefore hold both possibilities simultaneously — the potential for profound healing and the potential for harm.

Section 2.2: Core Trauma-Informed Principles Applied to KAP

1. Safety

Physical safety: comfortable, private, well-equipped space
Relational safety: established therapeutic alliance before the medicine session
Psychological safety: patient understands what to expect; has agency throughout

KAP application: Never conduct a medicine session before sufficient preparation. A minimum of 2–3 preparation sessions is standard; more may be needed for complex trauma histories.

2. Trustworthiness & Transparency

Full informed consent about what the experience may involve
Honest discussion of potential for difficult material to emerge
Clear explanation of therapist's role during the session

KAP application: Role-play the medicine session. Let the patient know how you will respond if they become distressed. Establish a word or signal for "I need you to speak to me."

3. Peer Support & Collaboration

Collaborative treatment planning
Patient retains agency over pacing

KAP application: The patient sets the intention; the therapist holds the container. Never impose a therapeutic agenda during the medicine session.

4. Empowerment & Choice

Patients maintain control over the experience as much as possible
Options for stopping or modifying the session

KAP application: Establish clear protocols for what happens if a patient wants to stop. Practice grounding techniques in preparation sessions.

5. Cultural, Historical & Gender Issues

Awareness of how cultural background affects the experience of altered states
Sensitivity to spiritual and religious frameworks
Awareness of historical trauma (e.g., medical mistrust in marginalized communities)

KAP application: Conduct a cultural assessment during preparation. Incorporate the patient's own meaning-making framework into integration.

Section 2.3: Trauma Presentations & KAP Modifications

Complex PTSD / Developmental Trauma

Requires more extensive preparation (often 4–6+ sessions)
Lower doses may be preferable initially
Strong emphasis on building window of tolerance before medicine session
Integration therapy may be longer and more intensive
Co-therapist or sitter model strongly recommended

Dissociative Disorders

Proceed with great caution
Ketamine's dissociative properties can worsen dissociative symptoms in vulnerable patients
Consult with a dissociative disorders specialist before proceeding
Structured dissociation protocols (e.g., parts-based work) during integration are essential

Single-Incident Trauma / PTSD

Generally more straightforward
Patient may have good ego strength and established coping skills
Standard preparation timeline often sufficient
Integration may focus on specific trauma processing

Somatic Trauma Storage

Train in Somatic Experiencing (SE) or Sensorimotor Psychotherapy principles
Ketamine can release somatically stored trauma — be prepared to work with body-based responses
During integration: titrate between cognitive meaning-making and somatic processing

Section 2.4: Polyvagal Theory Applied to KAP

Understanding Stephen Porges' Polyvagal Theory is essential for KAP:

Ventral Vagal (Safe/Social): The optimal state for both the medicine session and integration work. The therapist's primary job is to help the patient maintain or return to this state.
Sympathetic Activation (Fight/Flight): May emerge as anxiety, agitation, or panic during the session. Grounding, breath, and voice can help.
Dorsal Vagal (Shutdown/Freeze): Can appear as profound stillness, non-responsiveness, or dissociation. Gentle titration back to activation is needed.

Practice implication: Learn to read the patient's nervous system state through non-verbal cues. During the medicine session, your regulated nervous system co-regulates theirs.

Section 2.5: Stabilization Skills to Teach Patients Before KAP

Before any medicine session, ensure patients have mastered:

Diaphragmatic breathing and 4-7-8 breath
Grounding techniques (5-4-3-2-1 sensory, feet on floor, weighted blanket)
Safe/Calm place visualization
Containment imagery (for if traumatic material becomes overwhelming)
Window of Tolerance concept — patient can identify when they are within vs. outside it
Pendulation — ability to move between distress and resource states

Module 2 Readings & Resources

Van der Kolk, B. The Body Keeps the Score. Viking.
Levine, P. Waking the Tiger: Healing Trauma. North Atlantic Books.
Fisher, J. Transforming the Living Legacy of Trauma. PESI Publishing.
Dana, D. The Polyvagal Theory in Therapy. W.W. Norton.
Porges, S. The Polyvagal Theory. W.W. Norton.

Module 2 Self-Assessment

I can identify trauma presentations that require modified KAP approaches I understand polyvagal theory and can apply it in session I can teach patients stabilization skills before the medicine session I know when to slow down or defer a medicine session based on trauma presentation I have a plan for managing trauma activation during a medicine session

Module 3

Non-Ordinary States of Consciousness (NOSC)

Learning Objectives

Develop a theoretical and experiential framework for non-ordinary states
Understand the phenomenology of the ketamine experience
Learn to navigate common and challenging NOSC presentations
Cultivate therapeutic presence appropriate for altered state work

Section 3.1: Theoretical Frameworks for NOSC

Stanislav Grof's Transpersonal Psychology

Grof, a pioneer of psychedelic-assisted therapy, described several categories of experience in NOSC:

Sensory/Aesthetic: Visual phenomena, altered perception of time and space
Psychodynamic/Biographical: Surfacing of personal memories, emotions, relational patterns
Perinatal: Experiences related to birth, death, profound transformation
Transpersonal: Mystical, spiritual, or unity experiences beyond personal identity

All four may occur during KAP sessions. The therapist needs a framework that can hold all of these without pathologizing them.

William James' Characteristics of Mystical Experience

Many patients report experiences with these qualities:

Noetic quality — a sense of profound insight or revelation
Ineffability — difficulty putting the experience into words
Transiency — temporary, but leaving a lasting impression
Passivity — a sense of being acted upon rather than directing

These experiences can be profoundly healing — particularly for patients with depression or existential distress. The integration therapist helps the patient extract meaning and apply it.

The Default Mode Network Model

Modern neuroscience supports the following model:

The DMN is associated with self-referential rumination, rigid narrative identity, and depression
Ketamine (and other psychedelics) disrupt DMN activity
This creates an "entropic brain" state — temporarily more flexible, less rigid
During this window, the patient may experience self-transcendence, novel perspectives, and reduced self-criticism
Integration work helps consolidate these new perspectives into lasting change

Section 3.2: Phenomenology of the Ketamine Experience

Common Experiences by Dose

Low dose (sub-psychedelic)

Mild relaxation and mood elevation
Reduced pain and anxiety
Slight perceptual changes
Full verbal communication usually maintained
Often described as "floaty" or "dreamy"

Moderate dose (psychedelic threshold)

Significant dissociation from ordinary reality
Visual phenomena (patterns, colors, geometric forms)
Altered sense of time (often slowed or suspended)
Emotional release possible
Reduced verbal communication; internal experience dominant
Body may feel heavy or distant

Higher dose (full dissociative/psychedelic)

Profound ego dissolution possible
Out-of-body or near-death type experiences
Mystical/unity experiences
Minimal verbal communication
Patient largely in an internal world
Integration is particularly important at this level

The "K-Hole"

At very high doses, patients may enter a deeply dissociated state sometimes called the "K-hole" — characterized by profound loss of contact with ordinary reality, immobility, and intense internal experience. In therapeutic settings, this is generally avoided through careful dosing, but therapists should be prepared to hold the space calmly if it occurs.

Section 3.3: The Therapist's Role in NOSC

Core Principle: Non-Directive Presence

The primary therapeutic stance during a medicine session is presence, not intervention. The therapist's job is to:

Hold a safe, regulated, non-anxious container
Trust the patient's inner healing intelligence
Intervene minimally and only when needed
Follow rather than lead

The INNER acronym (adapted from psychedelic therapy literature)

Intention — trust the patient's intention for the session
Non-interference — allow the experience to unfold
Non-judgment — all experiences are valid, none are "wrong"
Empathy — maintain attunement even without words
Reassurance — offer brief, grounding statements if distress arises

Appropriate Interventions During the Session

Grounding statements: "You are safe. I am here. This will pass."
Breath reminders: Gentle cue to breathe if patient appears to be holding breath
Reassurance during difficult passages: "You can let go. It's safe to move through this."
Minimal touch (if pre-consented and appropriate): Hand on hand or shoulder for grounding
Music adjustment if the patient is clearly distressed by the current track

What NOT to Do During the Session

Do not engage in lengthy verbal conversation — this pulls the patient out of the internal experience
Do not interpret or analyze during the session — save this for integration
Do not introduce new therapeutic content or questions
Do not leave the patient unattended
Do not share your own reactions or experiences

Section 3.4: Music in KAP

Music is a powerful therapeutic tool in KAP and other psychedelic-assisted therapies. Principles:

Music helps pace and guide the emotional arc of the session
Build playlists with intention: gentle opening → deepening → peak → return → grounding
Avoid music with lyrics (especially in English) during peak phases — verbal content can be intrusive
Recommended resources: Wavepaths (Johns Hopkins-inspired playlists), Musicmedicine.com
Discuss music preferences with patient in preparation — some patients have strong associations
Always have a plan to change or pause music if the patient is distressed

Section 3.5: Cultivating Therapeutic Presence for NOSC Work

This is perhaps the most challenging aspect to develop through self-guided study alone. It requires:

Personal work

Your own experience with non-ordinary states (see Module 5)
Regular meditation or mindfulness practice
Personal therapy to address your own unresolved material
Work with a supervisor who has NOSC experience

Skills to develop

Equanimity — the ability to remain calm when the patient is distressed
Presence without agenda — genuine curiosity rather than goal-orientation
Comfort with silence — resisting the urge to fill space
Non-verbal attunement — reading the patient's state through posture, breath, expression
Grounded physical presence — your nervous system regulates theirs

Recommended Practice: Engage in a personal meditation practice of at least 20 minutes daily throughout this training. Practices such as mindfulness, yoga nidra, or holotropic breathwork (as a participant) can develop the capacity for presence in altered states.

Module 3 Readings & Resources

Grof, S. The Way of the Psychonaut, Vol. 1 & 2. MAPS Press.
Grof, S. Healing Our Deepest Wounds. Stream of Experience Productions.
Richards, W. Sacred Knowledge: Psychedelics and Religious Experiences. Columbia University Press.
Watts, R. & Luoma, J. (2020). "The Use of the Psychological Flexibility Model to Support Psychedelic-Assisted Therapy." Journal of Contextual Behavioral Science.
Film: Fantastic Fungi (Netflix) — accessible introduction to altered states and consciousness
Podcast: Psychedelic Therapy Frontiers — clinical discussions

Module 3 Self-Assessment

I can describe the phenomenology of the ketamine experience across dose ranges I have a theoretical framework for understanding mystical or transpersonal experiences I understand the role of music in guiding the session I can describe appropriate vs. inappropriate therapist interventions during the medicine session I am actively developing my capacity for equanimity and non-directive presence

Module 4

Target Populations & Clinical Assessment

Learning Objectives

Conduct comprehensive KAP-specific clinical assessments
Identify ideal candidates and recognize contraindications
Tailor KAP approaches to specific diagnostic presentations
Collaborate effectively with the prescribing provider

Section 4.1: Primary Target Populations

Treatment-Resistant Depression (TRD)

Definition: Failure to achieve adequate response after ≥2 antidepressant trials of adequate dose and duration
KAP rationale: Ketamine provides rapid neuroplasticity; KAP uses this window to address cognitive, behavioral, and relational patterns maintaining depression
Assessment focus: Depression severity (PHQ-9), suicidality (C-SSRS), prior treatment history, psychosocial maintaining factors
Integration focus: Behavioral activation, cognitive restructuring, schema work, relational patterns, meaning and purpose

Major Depressive Disorder (MDD) — Severe or Urgent Presentations

KAP rationale: Ketamine's rapid onset (often within 24–48 hours) is valuable when standard antidepressants' 4–6 week delay is clinically risky
Assessment focus: Acute suicidal ideation, safety planning, level of care determination
Note: Patients with active suicidal ideation require careful safety planning and potentially higher level of care in conjunction with KAP

PTSD

KAP rationale: Ketamine may disrupt reconsolidation of fear memories; the altered state can provide access to traumatic material with reduced defensive reactivity
Assessment focus: PCL-5, trauma history (ACEs, type, duration, chronicity), dissociative symptoms (DES-II), attachment style, current safety
Integration focus: Trauma processing (IFS, somatic, EMDR-informed), narrative reconstruction, meaning-making, safety and trust

OCD

KAP rationale: Emerging evidence; ketamine may disrupt rigid OCD-related neural circuits; integration addresses the psychological maintaining factors
Assessment focus: Y-BOCS, ego-syntonic vs. ego-dystonic presentation, insight level, treatment history
Integration focus: ERP principles, ACT (defusion from obsessional thoughts), values-based action

Generalized Anxiety Disorder / Treatment-Resistant Anxiety

KAP rationale: Ketamine's anxiolytic properties plus the integration of anxiety-maintaining beliefs and avoidance patterns
Assessment focus: GAD-7, safety behaviors, avoidance patterns, somatic presentation
Integration focus: ACT, somatic awareness, interoceptive exposure, worry postponement

Bipolar Depression

Proceed with caution: Risk of switching to mania or hypomania
Prerequisites: Mood stabilizer coverage; prescriber oversight essential; careful monitoring
KAP rationale: When depression is treatment-resistant and patient is mood-stabilized
Integration focus: Mood monitoring, sleep hygiene, identifying prodromal symptoms, lifestyle regulation

Substance Use Disorders

Primary focus: Alcohol Use Disorder (AUD) — the most evidence-based application
KAP rationale: Disruption of addictive behavior patterns during the neuroplasticity window; motivational enhancement
Assessment focus: AUDIT, stage of change, withdrawal risk, co-occurring psychiatric conditions
Integration focus: Motivational interviewing, values clarification, relapse prevention, 12-step integration if relevant
Caution: Active use of dissociatives or high-dose cannabis; active alcohol dependence requires medically supervised detox first

End-of-Life / Existential Distress

KAP rationale: Ketamine's capacity to induce mystical/transcendent experiences can profoundly shift relationship to death and dying
Assessment focus: Existential concerns, spiritual/religious framework, goals of care, family system
Integration focus: Meaning-making, legacy work, grief, spiritual integration, acceptance

Section 4.2: Contraindications

Absolute Contraindications

Active psychosis or schizophrenia spectrum disorder
Uncontrolled hypertension (BP >160/100 without treatment)
Active mania
Known allergy or adverse reaction to ketamine
Pregnancy
Severe hepatic impairment
Current use of MAOIs

Relative Contraindications (Require Careful Evaluation)

Dissociative Identity Disorder or severe dissociation — requires specialist consultation
Borderline Personality Disorder — can be treated with extensive preparation and support structure; not an automatic exclusion
Active suicidal ideation with plan/intent — requires stabilization and level of care review first
Moderate-severe substance use disorder (active) — requires stabilization first
Cardiovascular disease — medical clearance required
History of psychosis — evaluate carefully; may be appropriate in some cases with prescriber oversight
Severe personality pathology with poor reality testing

Section 4.3: The KAP Clinical Assessment

Recommended Assessment Battery

PHQ-9 — depression severity
GAD-7 — anxiety severity
PCL-5 — PTSD symptoms
C-SSRS — Columbia Suicide Severity Rating Scale
DES-II — Dissociative Experiences Scale
ACE Questionnaire — Adverse Childhood Experiences
AUDIT — Alcohol Use Disorders Identification Test
MDQ — Mood Disorder Questionnaire (screen for bipolar)

Clinical Interview Areas

Full psychiatric history including all prior treatments
Trauma history — type, duration, age of onset, prior processing
Substance use history — current and historical
Attachment history — early relationships, current relational patterns
Current psychosocial stressors and supports
Spiritual/philosophical framework and relationship to meaning
Prior experiences with altered states (meditation, anesthesia, recreational substances — non-judgmentally)
Goals and intentions for KAP
Support system availability for integration period
Practical logistics — transportation, safe home environment

Collaborative Communication with the Prescribing Provider

Share clinical assessment findings relevant to dosing and medical management
Discuss trauma history that may affect the session
Agree on session structure, monitoring, and emergency protocols
Establish clear communication channels for between-session concerns

Module 4 Readings & Resources

American Psychiatric Association. DSM-5-TR. APA Publishing.
Feder, A. et al. (2021). "Efficacy of Intravenous Ketamine for Treatment of Chronic Posttraumatic Stress Disorder." JAMA Psychiatry.
Krupitsky, E. et al. (2002). "Ketamine psychedelic therapy (KPT): A review of the results of ten years of research." Journal of Psychoactive Drugs.
Wolfson, P. (2014). "Ketamine — The New Psychedelic." Multidisciplinary Association for Psychedelic Studies Bulletin.

Module 4 Self-Assessment

I can conduct a comprehensive KAP-specific clinical assessment I can identify absolute and relative contraindications I understand how to tailor KAP to each target population I can communicate effectively with a prescribing provider about patient suitability I am using standardized assessment tools in my intake process

Module 5

Personal Psychotherapy & Experiential Preparation

Learning Objectives

Understand why personal work is considered essential for KAP therapists
Engage in sufficient personal therapy to identify countertransference vulnerabilities
Develop firsthand understanding of altered states (where legally permissible)
Cultivate the inner resources necessary for therapeutic presence

Section 5.1: Why Personal Work is Non-Negotiable

Every major psychedelic and ketamine therapy training program — from MAPS to Fluence to CIIS — requires personal experiential work as a core component. This is not arbitrary. Consider:

Countertransference in Altered States

When a patient is in a deeply altered, vulnerable state, the therapist is exposed to powerful emotional, spiritual, and relational material. Without sufficient personal processing, a therapist may:

Become anxious and over-intervene, disrupting the patient's process
Unconsciously steer the patient toward the therapist's own unresolved material
Project their own fear of certain experiences onto the patient
Be pulled into unhealthy dynamics (savior role, enmeshment, over-identification)
Develop compassion fatigue or vicarious traumatization without awareness

Authentic Presence

Patients in altered states are extraordinarily attuned to the therapist's authenticity. Unresolved material creates subtle but detectable incongruence. Personal work builds genuine equanimity — not performed calm, but actual settled presence.

Understanding the Experience from the Inside

A therapist who has never experienced a non-ordinary state of consciousness is somewhat like a travel guide who has never visited the destination. Experiential training builds:

Genuine empathy for the difficulty and beauty of the experience
Visceral understanding of what the patient may need in different moments
The ability to guide without over-explaining or intellectualizing

Section 5.2: Recommended Personal Work

Personal Psychotherapy

Engage in a minimum of 50+ hours of personal therapy before beginning KAP practice (many practitioners recommend 100+)
Ideally with a therapist who has familiarity with trauma and/or psychedelic work
Focus areas: attachment patterns, unresolved trauma, personal loss, identity, countertransference-prone areas
Continue therapy throughout your KAP practice

Personal Experiential Work with Non-Ordinary States

The following are legal options that can develop familiarity with altered states:

Holotropic Breathwork (Grof Transpersonal Training) — the closest legal analogue to psychedelic experience; highly recommended
Ketamine experience as a patient — if you have a qualifying condition, pursuing your own KAP is the most directly relevant experience. Many training programs explicitly encourage this.
Deep meditation retreats (Vipassana, Zen, Tibetan) — can induce NOSC with dedicated practice
Yoga Nidra / non-sleep deep rest practices — accessible altered state practice
EMDR as a client — bilateral stimulation can produce altered state-adjacent experiences
Somatic Experiencing as a client — body-based work that accesses non-ordinary material

Note on psychedelic experience: In jurisdictions where psilocybin or MDMA is legally available in clinical contexts (e.g., Oregon for psilocybin), therapist-trainees are increasingly encouraged to pursue supervised experiences. This is an evolving area.

Ongoing Self-Care Structure

KAP work is emotionally demanding. Establish before beginning practice:

Regular supervision (individual or peer group)
Consistent personal therapy
Daily mindfulness or somatic practice
Peer consultation network
Clear caseload limits to prevent burnout

Section 5.3: Reflective Practice Exercises

Throughout your training, maintain a Reflective Journal addressing:

What drew you to this work? What are your intentions?
What are your beliefs about consciousness, healing, and transformation?
What experiences have you had with altered states? What did you learn?
Where do you feel most vulnerable in therapeutic relationships? Where do boundaries blur?
What are your personal areas of unresolved grief, trauma, or loss?
How do you respond when patients are in extreme emotional distress? What arises in you?
What does "surrendering control" mean to you? How comfortable are you with uncertainty?
What are your spiritual or existential beliefs? How might these affect your work?
What is your relationship to psychoactive substances personally and professionally?
Who are your models of therapeutic presence? What do they embody that you aspire to?

Module 5 Resources

Grof, S. Psychology of the Future. SUNY Press.
Kornfield, J. A Path with Heart. Bantam Books.
Yalom, I. The Gift of Therapy. HarperCollins.
Grof Transpersonal Training: holotropicbreathwork.net
Practice: Commit to a daily meditation or somatic practice of minimum 20 minutes throughout this training program

Module 6

Core KAP Clinical Skills — The Preparation Phase

Learning Objectives

Conduct structured preparation sessions that optimize therapeutic outcomes
Develop the therapeutic alliance necessary to hold the medicine session safely
Set meaningful intentions collaboratively with the patient
Prepare the patient practically and psychologically for the experience

Section 6.1: Overview of the Preparation Phase

Minimum standard: 2–3 preparation sessions before the first medicine session
Complex presentations: For complex trauma or high-anxiety presentations: 4–8+ sessions
Session length: 50–90 minutes
Goal: The patient enters the medicine session feeling safe, prepared, and intentional — not fearful or unprepared

Section 6.2: Preparation Session 1 — Foundation

Goals

Complete clinical assessment (Module 4)
Begin building therapeutic alliance
Provide comprehensive psychoeducation about KAP
Assess and address fears or misconceptions
Introduce stabilization skills

Psychoeducation Content

What ketamine does in the brain (in accessible language)
The neuroplasticity window and why integration matters
What the experience may feel like at the planned dose
The therapist's role during the session (present, not directing)
What "difficult" experiences may feel like and how to work with them
The importance of "letting go" vs. fighting the experience
What happens after the session (integration period)

Key Skill to Teach: "Letting Go"

One of the most important preparation skills is teaching the patient to surrender to the experience rather than resist it. The instruction:

"Whatever comes up — emotions, images, physical sensations, strange thoughts — your job is to meet it with curiosity rather than resistance. If it feels like something is pulling you somewhere, go with it. The more you can relax and trust the experience, the more you will get from it. You don't have to figure anything out during the session — just allow."

Section 6.3: Preparation Session 2 — Intentions & Psychodynamic Exploration

Goals

Explore the patient's life story as relevant to their presenting concerns
Identify core themes, wounds, defenses, and growth edges
Begin formulating therapeutic intentions for the session
Deepen the therapeutic relationship

Intention Setting

An intention is different from a goal. Goals are outcomes; intentions are orientations.

Poor intention"I want to stop being depressed."

Better intention"I want to understand what is keeping me stuck and find a way forward."

Best intention"I want to open to whatever needs to be seen and healed."

Intentions should be:

Open rather than specific
Oriented toward insight and opening rather than demanding specific outcomes
Written down and reviewed at the start of the medicine session
Held lightly — not clung to if the experience goes elsewhere

Questions to Explore

"What do you most need from this experience?"
"What part of yourself are you most disconnected from?"
"What are you most afraid might come up? What if it did — what would that mean?"
"What would healing look like for you in the deepest sense?"
"Is there anything that feels unfinished — a relationship, a loss, something you haven't let yourself feel?"

Section 6.4: Preparation Session 3 — Practical Preparation & Logistics

Goals

Review and address remaining fears or questions
Practice stabilization skills and confirm patient competency
Establish session logistics and agreements
Confirm support system for integration period
Finalize intentions

Session Logistics to Confirm

Date, time, location of medicine session
Transportation plan (patient must not drive)
Who will be with them afterward
What to eat/drink beforehand (typically light meal 2–4 hrs prior; no alcohol 24 hrs prior)
Clothing (comfortable; layers for temperature regulation)
Personal items to bring (photographs, meaningful objects, journal)
Music preferences (discussed and planned)
Eye mask — discuss use; many patients benefit from inward focus with eye mask

Establishing Agreements

Confidentiality and its limits
Between-session contact protocols (especially for the integration period)
What to do if they feel unsafe at home after the session
Safety planning if relevant (suicidal ideation history)
Touch protocol — explicit consent discussion: "During the session, I may offer to hold your hand if you seem distressed. I'll ask first. Is that something you'd find helpful or would you prefer I not touch you?"

Confirm Integration Support

Who knows they are doing this? Who can support them?
Work/schedule — ideally a light day after the session
Journal available for capturing insights immediately after
Follow-up integration session scheduled (within 48–72 hours ideally)

Module 6 Self-Assessment

I can conduct a structured 3-session preparation sequence I can teach patients stabilization skills and intention-setting I understand the difference between goals and intentions in KAP I have established clear agreements and logistics protocols I am comfortable discussing the medicine session, including difficult experiences, openly

Module 7

Core KAP Clinical Skills — The Medicine Session

Learning Objectives

Facilitate the medicine session safely and therapeutically
Maintain appropriate presence and boundaries throughout
Recognize and respond to difficult or adverse experiences
Document the session appropriately

Section 7.1: Setting Up the Space

The physical environment of the medicine session is a therapeutic tool — sometimes called "the container." Attend to:

Physical Environment

Private, sound-proofed room — no interruptions
Comfortable reclining surface (therapy couch, recliner, or mat)
Blankets, pillows, weighted blanket available
Eye mask available (encourage patient to use during peak phase)
Tissues and emesis basin (nausea can occur, especially IM)
Water available
Soft, indirect lighting — dimmable preferred
Temperature controllable — patients often feel cold during sessions
Natural elements if possible (plants, natural light)
Absence of clinical/medical aesthetic where possible — warmth over sterility

Music

Curated playlist ready and tested
Wireless speaker placed optimally
Volume at comfortable background level — not overwhelming

Therapist Preparation

Arrive early; settle your own nervous system
Brief personal grounding practice before patient arrives
Phone off or silenced
Review patient's intentions from preparation

Section 7.2: Session Structure

Pre-Session Check-in (10–15 minutes)

Welcome, brief grounding
Review intentions together
Address any last-minute concerns or questions
Affirm the patient's readiness and the safety of the space
Final instruction: "Your only job today is to allow. Whatever comes up, we'll work with it together."

Administration (Prescriber's role)

The prescribing provider administers the ketamine. The therapist is present but not responsible for medical monitoring. Clarify with the prescriber who is responsible for vital signs monitoring.

Onset Phase (0–15 minutes)

Ketamine begins to take effect
Patient may feel relaxed, floaty, mildly dissociated
Encourage closing eyes and turning attention inward
Music begins — opening playlist
Minimal verbal interaction from therapist: "I'm right here. Just allow yourself to go where the medicine takes you."

Peak Phase (15–45 minutes depending on route)

Maximum dissociation and altered state
Therapist in silent, present witness mode
Monitor non-verbally: breath rate, body tension, facial expression, movement
Music in deepening/peak phase
Minimal intervention unless distress is evident (see Section 7.3)

Return Phase (45–75 minutes)

Patient begins returning to ordinary consciousness
May be talkative, emotional, or quiet
Offer water, tissues
Begin gentle, open-ended conversation: "How are you? What was that like for you?"
Do NOT begin formal integration work yet — this is too early
Allow the patient to share freely without interpretation
Music shifts to grounding/return playlist

Post-Session Integration Window (75–90 minutes)

Patient is more fully returned but still in a softened state
Gentle exploration of the experience: "What stands out most?"
Begin bridging: "Is there anything from the experience that feels relevant to your life?"
Encourage journaling that evening
Confirm next integration session
Review safety and aftercare: "How are you feeling? Do you feel ready to be with your support person?"
No driving for 12+ hours; light activity recommended; no alcohol

Section 7.3: Managing Difficult Experiences

Anxiety / Panic

Voice: calm, slow, low tone — "You are safe. I am right here. This will pass."
Breath guidance: "Try to breathe slowly and deeply."
Presence: Move closer if patient seems to need it
Grounding: "Feel your body in the chair. Feel the weight of the blanket."
Touch (if consented): Gentle hand on hand or shoulder
Do NOT ask the patient to describe what's happening — this can amplify it

Emergence of Traumatic Material

Stay calm — this is often therapeutically valuable
Do not redirect away from it during the session
"You are safe. Whatever is coming up, you can let it move through you."
After the session: "It sounds like some important material came up. We'll work with that in our integration sessions."

Dissociative Episode

Gentle grounding: "Can you feel your feet? Can you hear my voice?"
Increase verbal contact slightly
Do not panic — mild dissociation is expected; only intervene if patient appears distressed or unable to make any contact

Nausea / Physical Discomfort

Have emesis basin available
Reassure: "Nausea sometimes happens. It will pass."
Adjust position if needed (in coordination with prescriber)
Cool cloth to forehead if helpful

Crying / Grief

Do not interrupt or comfort prematurely — this may be therapeutically important
"It's okay to feel whatever you're feeling. I'm here."
Allow full expression

Unexpected Positive/Euphoric Experiences

Less intervention needed
Simply witness and allow
Note: Euphoria can sometimes be a defensive state — address in integration

Medical Emergency Protocol

Know your escalation pathway before the session begins
Have emergency numbers posted
Know location of emergency equipment
Prescribing provider should remain in the facility or on immediate call
For any medical concern: notify prescriber immediately

Section 7.4: Documentation

Document within 24 hours:

Patient presentation before session
Intentions stated
Dose and route administered (from prescriber's notes; confirm accuracy)
Timeline of session phases
Patient's verbal and non-verbal presentation throughout
Any notable themes, imagery, or emotional content shared
Interventions made by therapist
Patient's state at discharge
Plan for integration session

Module 7 Resources

Phelps, J. (2017). Developing Guidelines and Competencies for the Training of Psychedelic Therapists.
Multidisciplinary Association for Psychedelic Studies (MAPS) Therapist Training Manual (available to MAPS training participants)
Wavepaths platform for therapeutic music curation: wavepaths.com
Fluence Training KAP Medicine Session Guidelines (available through Fluence enrollment)

Module 7 Self-Assessment

I can set up a therapeutic space that supports the medicine session I can maintain appropriate presence throughout a 90-minute session I know how to respond to anxiety, panic, trauma activation, and nausea I have a clear escalation protocol for medical emergencies I can document the session comprehensively within 24 hours

Module 8

Core KAP Clinical Skills — The Integration Phase

Learning Objectives

Understand the neuroscience and psychology of integration
Conduct structured integration sessions within the neuroplasticity window
Apply multiple therapeutic modalities to integration work
Recognize and manage integration challenges

Section 8.1: What is Integration?

Integration is the process by which the experiences, insights, and emotional material from the medicine session are metabolized, understood, and woven into lasting psychological change.

Without integration

Insights remain ephemeral — interesting but not transformative
The neuroplasticity window closes without being utilized
Patients may return to old patterns even after positive medicine session experiences
Distressing experiences may remain unprocessed and potentially destabilizing

With integration

Novel perspectives become new ways of thinking and behaving
Emotional material that surfaced is processed and resolved
Insights are translated into concrete behavioral and relational changes
The medicine experience becomes a reference point for ongoing growth

The Integration Timeline

24–72 hours post-session: First integration session — highest priority window. The experience is fresh; the neuroplasticity is at peak.
Week 1–2: 1–2 additional integration sessions. Working with themes, emotions, and insights.
Week 2–4: Integration may slow and deepen. Behavioral changes begin to consolidate.
Week 4–6: Assess for additional ketamine sessions if planned; review gains; identify remaining areas of work.

Section 8.2: The First Integration Session

Timing: Within 48–72 hours of the medicine session
Length: 60–90 minutes
Tone: Open, exploratory, non-interpretive initially

Structure

Check-in — How is the patient doing physically and emotionally?
Narrative — "Tell me about your experience. Walk me through it."
Listen without interpretation; simply receive
Ask open clarifying questions: "What was that like?" "What happened next?"
Identify themes — "What stands out most as we've talked through this?"
Emotional processing — "What feelings are most alive right now as you describe this?"
Initial meaning-making — "What does this mean to you?"
Bridging — "Is there any connection between what came up in the session and your life outside of it?"
Plan — What practices, reflections, or behavioral experiments might support the integration?

What to Avoid in the First Integration Session

Over-interpretation or analysis
Challenging the patient's meaning-making (even if it seems off-base)
Introducing new therapeutic material unrelated to the experience
Rushing toward behavioral goals before the experience is fully processed

Section 8.3: Integration Modalities

Different therapeutic modalities contribute uniquely to integration work. Familiarity with the following is recommended:

Internal Family Systems (IFS) — Highly Recommended

IFS is particularly well-suited to KAP integration because:

Ketamine often produces spontaneous parts-like experiences (encountering aspects of self as separate entities)
The "Self" state cultivated in IFS resembles the expanded state of the medicine session
Parts that were activated during the session can be identified and worked with directly

Application: "In your session, you described encountering a young version of yourself. In IFS, we might call this an 'exile' — a part that holds pain from the past. Can we slow down and get curious about what that part needs?"

Somatic Experiencing / Sensorimotor Psychotherapy

Ketamine often produces somatic experiences — physical sensations, body memories, releases. Integration must include the body.

Application: "You mentioned feeling a heaviness in your chest during the session. Can you locate that sensation now? What happens if we stay with it?"

EMDR-Informed Integration

While full EMDR protocols are not typically used immediately post-session, EMDR principles (bilateral stimulation, targeting residual disturbance) can be useful later in the integration period.

Application: For traumatic material that emerged in the session, use EMDR processing in subsequent integration sessions once the patient is sufficiently stabilized.

Acceptance and Commitment Therapy (ACT)

ACT's emphasis on psychological flexibility, values, and defusion is highly compatible with the post-ketamine state.

Application: "In your session, you described feeling completely free from the self-criticism that usually dominates your mind. ACT would say you had a moment of 'defusion' from that thought. What would your life look like if you could relate to that critical voice the way you did during the session?"

Psychodynamic Approaches

Ketamine can surface early relational patterns, attachment wounds, and unconscious material.

Application: Explore the symbolism and emotional significance of images or experiences from the session using psychodynamic listening: "What comes to mind when you think about that image of the dark water? Where else in your life have you felt that way?"

Existential/Meaning-Centered Approaches

Particularly relevant for end-of-life cases, spiritual emergence, or patients whose sessions had transpersonal qualities.

Application: "You described a sense of unity with everything around you. How does that experience sit alongside your fears about death? Has anything shifted?"

Narrative Therapy

Help the patient re-author their story in light of new insights.

Application: "You've described yourself as 'someone who can't connect with others.' After what you experienced in the session — that sense of love and openness — does that description still fit? What might be a truer description?"

Section 8.4: Integration Challenges

The "Afterglow" Phenomenon

Many patients feel an initial euphoric or elevated mood after the session. This can be misleading:

Validate and explore the experience
Gently note that integration work continues beyond the afterglow
Use the elevated mood to build momentum for behavioral change
Caution against over-scheduling or making major life decisions impulsively

Destabilization / Psychological Crisis

Occasionally, difficult material from the session can destabilize a patient in the days following:

Watch for increased depression, anxiety, intrusive symptoms, or dissociation
Daily check-ins may be warranted in the first week post-session for vulnerable patients
Have a clear crisis protocol: who does the patient call? What is the escalation pathway?
Consider whether a lower dose is appropriate for future sessions

Spiritual Emergency

Some patients experience a profound shift in their sense of self or reality that can be both meaningful and destabilizing (Grof's "spiritual emergency"):

Symptoms may include: altered sense of identity, synchronicity preoccupation, confusion about what's real, grandiosity or awe states that interfere with function
Do NOT pathologize — but also do NOT leave unmonitored
Grounding: routine, sleep, exercise, social contact
Refer to Grof Transpersonal Training resources on spiritual emergency support

Resistance to Integration

Some patients intellectualize the experience without engaging emotionally or behaviorally:

Gently name the pattern: "I notice we've talked about what happened a lot, but I'm curious how it's showing up in your day-to-day life."
Body-based work can bypass intellectual resistance
Explore fear of change or loss of identity that might underlie resistance

Memory Fragmentation

Ketamine can produce fragmented or difficult-to-recall experiences:

Encourage journaling immediately after the session
Use sensory and somatic cues to access memory: "What do you remember about how your body felt?"
Fragmented memories can still be integrated around themes and feelings even without narrative coherence

Section 8.5: Behavioral Integration

Integration is not only about processing the experience — it must produce change in daily life:

Behavioral Experiments

Collaboratively identify 1–2 concrete behavioral changes the patient can try during the integration window:

Reconnecting with an estranged relationship
Beginning a creative practice that felt meaningful in the session
Stopping an avoidance behavior that was illuminated during the session

Lifestyle Integration

Sleep: prioritize adequate sleep during the integration period (consolidates learning)
Exercise: gentle movement supports somatic integration
Journaling: daily writing during the first 2 weeks
Mindfulness: even 10 minutes daily supports neuroplasticity
Limit alcohol and cannabis during integration period (both impair neuroplasticity)

Follow-Up Assessment

Re-administer clinical measures at 4–6 weeks post-session:

PHQ-9, GAD-7, PCL-5
Compare to baseline
Inform decision about additional KAP sessions

Module 8 Resources

Schwartz, R. No Bad Parts: Healing Trauma and Restoring Wholeness with the Internal Family Systems Model. Sounds True.
Levine, P. In an Unspoken Voice: How the Body Releases Trauma. North Atlantic Books.
Hayes, S. A Liberated Mind: How to Pivot Toward What Matters. Avery.
Mithoefer, M. (2017). MAPS MDMA-Assisted Psychotherapy Treatment Manual — Integration section (available at maps.org)
Eisner, B. Ecstasy: The MDMA Story. Ronin Publishing. (For integration framework history)

Module 8 Self-Assessment

I can conduct a structured first integration session within 72 hours of the medicine session I can apply IFS, somatic, ACT, and psychodynamic approaches to integration I can recognize and manage integration challenges including destabilization and spiritual emergency I understand the neuroplasticity window and can pace integration accordingly I have protocols for crisis management during the integration period

Module 9

Ethics, Safety & Boundaries

Learning Objectives

Apply ethical principles specific to the heightened vulnerability of KAP
Maintain clear professional boundaries throughout the KAP relationship
Navigate power differentials consciously
Understand reporting obligations and legal protections

Section 9.1: Why Ethics Require Special Attention in KAP

Psychedelic and ketamine-assisted therapy contexts create unique ethical risks:

Patients in altered states are profoundly vulnerable and highly suggestible
The therapeutic relationship is intensified — rapid depth, attachment, and transference
Experiences of unity, love, or spiritual connection can be misattributed to the therapist
The therapist holds significant power in structuring the patient's internal experience
The history of psychedelic therapy includes well-documented ethical violations — including sexual misconduct, boundary violations, and exploitation

A KAP therapist must maintain higher, not lower, ethical vigilance compared to standard practice.

Section 9.2: Boundary Management

The Therapeutic Frame

Maintain a clear and consistent frame:

Consistent scheduling, cancellation policies, billing
Clear role definition: you are the therapist, not a spiritual guide, friend, or guide to "enlightenment"
Predictable structure to the preparation-medicine-integration sequence

Physical Boundaries

Touch must be explicitly pre-consented in preparation sessions
Permissible (with consent): hand-holding for grounding; hand on shoulder for reassurance
Never permissible: any touch that could be sexualized; prolonged physical contact; holding patient in your lap or arms
Document any physical contact in session notes
If uncertain: do not touch

Relational Boundaries

Do not share your own personal experiences, opinions, or interpretations during the medicine session
Manage transference actively in integration — be aware when the patient idealizes you
Do not foster dependency — the goal is the patient's autonomous healing, not reliance on you
No dual relationships: do not treat friends, family, colleagues, or business associates
No personal social media connection during or after the therapeutic relationship

Post-Session Contact

Define in advance what is permissible (e.g., a brief check-in call the evening after the session)
Avoid lengthy between-session contacts that blur the therapeutic frame
Document all between-session contacts

Section 9.3: The Amplified Transference/Countertransference Dynamic

In KAP, transference and countertransference are significantly amplified:

Common Patient Transferences

Idealization of the therapist as a healer or spiritual figure
Intense attachment or dependency following the medicine session
Erotic transference — the experience of love/openness can be misdirected toward the therapist
Fear and distrust — if the session was difficult, the therapist may be blamed

Common Therapist Countertransferences

Over-identification with the patient's spiritual or transformative experience
Savior or guru impulse — wanting to be the agent of transformation
Vicarious trauma — particularly when traumatic material surfaces in sessions
Personal material activated by the patient's experience
Burnout or compassion fatigue over time

Managing Countertransference

Regular supervision — discuss countertransference openly and without shame
Personal therapy — ongoing processing of material activated by the work
Peer consultation — normalize the challenges with trusted colleagues
Self-awareness — maintain a reflective journal throughout your practice

Section 9.4: Informed Consent for KAP

A comprehensive KAP-specific informed consent document should cover:

Nature and purpose of KAP
What will happen in each phase (preparation, medicine session, integration)
Risks: psychological (difficulty, destabilization), physical (nausea, cardiovascular), and rare (psychosis)
Limits of confidentiality
Touch protocol
Photography/recording policy (none, generally)
Between-session contact policies
Emergency procedures
Patient's right to discontinue at any time
Alternative treatments available
Prescriber's separate consent for the ketamine administration

Have a mental health attorney review your consent documents for your jurisdiction.

Section 9.5: Mandatory Reporting & Legal Obligations

These are unchanged from standard practice but are worth reviewing in the KAP context:

Duty to warn/protect (Tarasoff): If patient reveals credible threat to another, you have an obligation to act
Child abuse/neglect reporting: Required in all states
Elder/dependent adult abuse: Required in most states
Suicidality: Follow your professional standards; have a clear safety planning protocol; know your local emergency resources
Documentation: Particularly important in KAP — document fully to protect both patient and practitioner

Section 9.6: Scope of Practice & Collaboration

Never administer ketamine — this is the prescriber's sole responsibility
Do not make medical recommendations about dosing, drug interactions, or medical management
Do not practice outside your licensure
Maintain a collaborative relationship with the prescribing provider with clear communication channels
Know when to refer: if a patient's needs exceed your competency, refer to appropriate specialists

Module 9 Resources

American Psychological Association. Ethical Principles of Psychologists and Code of Conduct. (or relevant code for your licensure)
NASW Code of Ethics (for social workers)
Barnett, J. & Johnson, W. Ethics Desk Reference for Psychologists. APA Publishing.
Reamer, F. Boundary Issues in Social Work. NASW Press.
Sessa, B. (2016). "The history of psychedelics in medicine." In Psychedelic Medicine. Springer.

Module 9 Self-Assessment

I have a KAP-specific informed consent document reviewed by legal counsel I can articulate clear physical and relational boundary protocols I actively manage countertransference through supervision and personal therapy I understand the amplified transference dynamics unique to KAP I know my mandatory reporting obligations in my jurisdiction

Appendix A

Assessment Tools

Download and familiarize yourself with:

PHQ-9 — Patient Health Questionnaire (depression)
GAD-7 — Generalized Anxiety Disorder scale
PCL-5 — PTSD Checklist for DSM-5
C-SSRS — Columbia Suicide Severity Rating Scale
DES-II — Dissociative Experiences Scale
ACE Questionnaire — Adverse Childhood Experiences
AUDIT — Alcohol Use Disorders Identification Test
MDQ — Mood Disorder Questionnaire

All are publicly available at no cost through their respective developers or the VA/DOD.

Appendix C

Professional Organizations & Ongoing Education

Organization	Focus	Website
ASKP3	Ketamine physicians & therapists	askp3.org
Fluence	KAP therapist training	fluencetraining.com
MAPS	Psychedelic-assisted therapy	maps.org
Grof Transpersonal Training	Holotropic Breathwork & NOSC	holotropicbreathwork.net
Clinical TMS Society	TMS + neuromodulation	clinicaltmssociety.org
CIIS	Academic psychedelic training	ciis.edu
IPI	Integrative Psychiatry	integrativepsychiatry.net

Appendix D

Sample Session Documentation Templates

Preparation Session Note

Date / Session number
Patient presentation / mood / affect
Topics covered (psychoeducation, intentions, stabilization skills)
Patient's stated concerns or questions
Skills practiced
Plan for next preparation session or medicine session
Risk assessment if indicated

Medicine Session Note

Date
Intentions stated by patient
Dose and route (from prescriber documentation)
Patient presentation pre-session
Timeline of session with observations (onset, peak, return)
Notable themes, images, emotional content
Therapist interventions
Patient state at session end
Aftercare instructions given
Integration session scheduled: date/time
Risk assessment

Integration Session Note

Date / Integration session number (e.g., "Integration Session 1 of 4")
Interval since medicine session
Patient's reported experience since session
Themes and content explored
Modalities used
Patient's emotional and cognitive response
Behavioral experiments or practices assigned
Assessment measures re-administered (if applicable)
Plan for next session
Risk assessment

This training program was developed for licensed mental health professionals working within an integrated TMS and KAP clinical practice. It is intended as a comprehensive self-guided curriculum to be completed alongside formal supervision, personal psychotherapy, and ideally enrollment in a recognized KAP training program. Clinical practice must remain within the scope of your licensure and in collaboration with a licensed prescribing provider.

Version 1.0 · For Internal Clinical Use

Ketamine-Integrated Psychotherapy (KAP)

Therapist-Prescriber Communication Protocol

Practice
Effective Date
Reviewed Annually By: Prescriber & Lead KAP Therapist

Purpose

This protocol defines the structure, content, timing, and documentation standards for all communication between the KAP therapist and prescribing provider. Clear, consistent communication between these roles is essential for patient safety, therapeutic coherence, and coordinated care.

Part 1

Roles & Responsibilities

The Prescribing Provider Is Responsible For:

Medical evaluation, clearance, and ongoing medical monitoring
Ketamine prescription, dosing decisions, and dose adjustments
Administration or oversight of administration of ketamine
Vital signs monitoring during the medicine session
Managing medical adverse events and emergencies
Communicating medication interactions and changes to the therapist
Medical documentation in the patient's chart

The KAP Therapist Is Responsible For:

Psychotherapeutic assessment and ongoing clinical evaluation
Preparation, medicine session facilitation, and integration therapy
Monitoring psychological stability and safety between sessions
Communicating clinically relevant findings to the prescriber
Safety planning and mental health crisis response
Psychotherapy documentation in the patient's chart

Shared Responsibilities:

Joint treatment planning and KAP candidacy decisions
Monitoring overall patient progress and treatment response
Adverse event identification and response
Decisions about continuation, modification, or discontinuation of KAP
Patient informed consent (each provider obtains consent for their scope)

Part 2

Communication Structure

2.1 Pre-Treatment Consultation (Required Before First Medicine Session)

When: After therapist completes initial assessment; before medicine session is scheduled
Format: In-person or video meeting (minimum 30 minutes)
Who: Prescriber + KAP therapist (patient not present)

Agenda

Review therapist's clinical assessment findings
Review prescriber's medical evaluation findings
Joint determination of KAP candidacy
Identify any contraindications or risk factors to address
Discuss trauma history and its implications for dosing and session management
Agree on route of administration, initial dose range, and session structure
Establish session monitoring roles and emergency protocol
Review patient's psychosocial support system
Agree on informed consent process
Schedule medicine session and confirm logistics

Documentation: Both providers document the consultation in their respective notes. Use the Pre-Treatment Consultation Summary Form (see Appendix A).

2.2 Pre-Medicine Session Briefing (Required Before Each Medicine Session)

When: Same day as medicine session, before patient arrives (10–15 minutes minimum)
Format: In-person preferred; phone/secure message acceptable
Who: Prescriber + therapist

Content

Therapist's summary of preparation session(s): patient's intentions, emotional state, identified concerns
Any between-session clinical developments (mood changes, stressors, medication changes)
Specific trauma or psychological material to be aware of during the session
Patient's anxiety level or specific fears about the session
Any requested modifications to the session structure
Confirmation of dose and route planned by prescriber
Confirmation of emergency protocol

Documentation: Brief pre-session note by therapist referencing the briefing.

2.3 Post-Medicine Session Debrief (Required After Each Medicine Session)

When: Immediately or within 2 hours after the medicine session concludes
Format: In-person (preferred, as both are present); brief structured verbal exchange
Who: Prescriber + therapist

Content

Therapist's summary of the session: notable themes, emotional content, patient's state
Prescriber's summary: medical observations, vital signs, any physical concerns
Patient's presentation at discharge: affect, orientation, safety
Any safety concerns identified (suicidality, destabilization)
Therapist's plan for integration session (timing confirmed)
Any dose modification considerations for future sessions
Agreed-upon patient follow-up if concerns were identified

Documentation: Both providers document observations in their session notes. Therapist uses Medicine Session Note Template (see Training Program Appendix D).

2.4 Integration Period Check-In

When: Within the 2–4 week neuroplasticity/integration window following each medicine session
Format: Brief written update via secure messaging (EHR or encrypted platform); escalate to phone/meeting if concerns arise
Who: Therapist initiates; prescriber responds as indicated

Therapist Communicates to Prescriber

Patient's psychological response to the session (positive, destabilizing, neutral)
Presence or absence of integration challenges (destabilization, spiritual emergency, crisis)
Patient-reported changes in mood, anxiety, or symptoms
Any safety concerns
Recommendation for or against additional ketamine session based on clinical response
Re-administered outcome measures (PHQ-9, GAD-7, PCL-5) results if completed

Prescriber Communicates to Therapist

Any medication changes made or planned
Medical concerns arising between sessions
Patient contacts to the prescriber's office between sessions
Decision-making about next ketamine session timing

Escalation Threshold

If therapist identifies any of the following, contact the prescriber same day by phone:

Active suicidal ideation with plan or intent
Significant psychological destabilization (psychosis, dissociative break, mania)
Patient expressing intent to harm others
Significant adverse physical symptoms reported

2.5 Treatment Review Meeting (Required Every 4–6 Weeks or After Each Treatment Series)

When: After completion of an acute treatment series (typically 4–6 sessions) or every 6 weeks for maintenance patients
Format: In-person or video; minimum 20–30 minutes
Who: Prescriber + therapist

Agenda

Review outcome measures (pre/post comparison)
Assess overall treatment response
Identify remaining clinical targets
Discuss quality of integration — what has changed psychologically?
Determine next phase: additional acute sessions, maintenance schedule, taper, or discharge
Medication review — any adjustments indicated?
Psychotherapy plan for ongoing integration
Any concerns about patient safety or adherence

Documentation: Use the Treatment Review Summary Form (see Appendix B). Both providers sign or co-document the treatment review.

2.6 Discharge / Treatment Completion Communication

When: Upon planned completion of KAP
Format: Joint note or co-signed discharge summary
Who: Prescriber + therapist

Content

Summary of treatment course (number of sessions, doses, route)
Clinical response and outcome measure comparison (baseline vs. end of treatment)
Psychological gains and remaining areas of work
Ongoing psychotherapy plan (if continuing with therapist)
Medication plan going forward
Maintenance KAP plan if applicable
Agreed-upon criteria for re-initiating KAP if relapse occurs
Follow-up plan and responsible provider for each domain

Part 3

Urgent & Emergency Communication

3.1 Urgent Communication Triggers

The therapist must contact the prescriber within the same business day for:

Patient reports of significant mood deterioration or return of severe symptoms
New or worsening suicidal ideation (passive)
Patient discloses new substance use during the integration period
Patient reports unusual physical symptoms potentially related to ketamine
Patient misses integration sessions and is not reachable
Patient reports dissociative symptoms that are new or worsening
New psychiatric diagnosis identified during treatment

3.2 Emergency Communication Triggers

The therapist must contact the prescriber immediately (by phone) for:

Active suicidal ideation with plan, intent, or means
Suicidal behavior or self-harm
Active psychosis or break from reality
Threat of violence to an identified third party
Medical emergency reported by patient (chest pain, seizure, severe dissociation)
Patient presents to emergency room

Emergency Contact Protocol

Situation	First Contact	If Unavailable
Psychiatric emergency	Prescriber direct cell	On-call provider → 988 / 911
Medical emergency	911	Notify prescriber immediately after
After-hours crisis	Prescriber on-call line	Crisis line → 988
Patient hospitalized	Prescriber (same day)	Practice manager

All providers must have the following posted in their workspace:

Prescriber's direct cell phone
Practice after-hours/on-call number
Local psychiatric emergency services
988 Suicide & Crisis Lifeline

Part 4

Documentation Standards

4.1 Shared Chart vs. Separate Documentation

Recommended: Maintain a single integrated EHR record with separate note types for therapist and prescriber documentation. If separate records are maintained, a release of information must be in place and copies of key communications must be filed in both records.

4.2 Communication Log

All significant therapist-prescriber communications should be logged. Use the Communication Log Template (Appendix C) or equivalent EHR communication function.

Each log entry includes:

Date and time
Method (in-person, phone, secure message)
Participants
Summary of content
Any decisions made
Follow-up actions assigned

4.3 Documentation Turnaround Standards

Document	Responsible Party	Turnaround
Pre-treatment consultation summary	Both providers	Within 24 hours of meeting
Preparation session note	Therapist	Within 24 hours
Medicine session note	Both providers	Within 24 hours
Integration session note	Therapist	Within 24 hours
Between-session communication log	Initiating provider	Same day
Treatment review summary	Both providers	Within 48 hours of meeting
Discharge summary	Both providers	Within 5 business days

Part 5

Confidentiality & Information Sharing

5.1 Release of Information

Before any communication between therapist and prescriber can occur, the patient must sign a Release of Information (ROI) authorizing the exchange of clinical information between the two providers.

The ROI should specify:

The names/roles of both providers
The purpose (coordination of KAP treatment)
What information may be shared (clinical assessments, session notes, safety concerns, outcome measures)
Duration of the authorization
Patient's right to revoke

5.2 Limits on Information Sharing

The therapist and prescriber share information relevant to treatment coordination and patient safety. The therapist is not required to share verbatim session content or details of the patient's disclosure unless relevant to:

Safety (suicidality, harm to others)
Medical management (e.g., undisclosed substance use affecting dosing)
Treatment planning decisions

5.3 Mandatory Reporting Obligations

If mandatory reporting is triggered during KAP (child abuse, elder abuse, duty to warn), the therapist:

Follows their standard mandatory reporting protocol
Notifies the prescriber that a report has been made (without necessarily sharing all content)
Documents the report and the prescriber notification in the chart

Part 6

Disagreements in Clinical Decision-Making

Therapist and prescriber may occasionally disagree about treatment decisions. Protocol:

Discuss directly — schedule a dedicated meeting to review the clinical reasoning on both sides
Patient-centered framework — ground the discussion in patient safety and best interest
Consult — if unresolved, seek consultation from a senior KAP clinician or supervisor
Document — document the disagreement, the consultation, and the final decision
Defer to safety — when in doubt, the more conservative clinical decision takes precedence

Protocol · Appendix A

Pre-Treatment Consultation Summary Form

Patient: ___________________________ DOB: ___________ MRN: ___________

Date of Consultation: _______________

Prescriber: ___________________________ Therapist: ___________________________

Clinical Summary (Therapist)

Primary diagnosis/diagnoses: _______________________________________________
Relevant trauma history: ___________________________________________________
Prior treatment history: ____________________________________________________
Psychosocial risk factors: __________________________________________________
Protective factors / support system: _________________________________________
Psychological readiness for KAP: ☐ Ready ☐ Additional prep needed ☐ Defer

Medical Summary (Prescriber)

Medical clearance: ☐ Cleared ☐ Conditional ☐ Not cleared
Relevant medical history: __________________________________________________
Current medications: ______________________________________________________
Contraindications reviewed: ☐ None identified ☐ Relative (specify): ____________
Planned route of administration: ☐ IV ☐ IM ☐ Oral/sublingual ☐ Intranasal
Initial dose range: ________________________________________________________

Joint Decisions

KAP candidacy confirmed: ☐ Yes ☐ No ☐ Deferred pending: _________________
Number of preparation sessions before medicine session: _______________________
Session monitoring assignments: ____________________________________________
Emergency protocol reviewed: ☐ Yes
Informed consent plan: ____________________________________________________
Medicine session scheduled: _______________________________________________

Signatures

Prescriber: ___________________________________ Date: _____________

Therapist: ____________________________________ Date: _____________

Protocol · Appendix B

Treatment Review Summary Form

Patient: ___________________________ DOB: ___________ MRN: ___________

Review Date: _______________ Treatment Series: Acute ☐ Maintenance ☐ Other ☐

Sessions Completed This Series: _______ Total Sessions to Date: _______

Outcome Measures

Measure	Baseline	Current	Change
PHQ-9
GAD-7
PCL-5
Other:

Clinical Response:

☐ Full response (>50% symptom reduction)

☐ Partial response (25–50% reduction)

☐ Minimal response (<25% reduction)

☐ No response

☐ Worsening

Integration Quality (Therapist Assessment)

Key psychological gains: ___________________________________________________
Remaining clinical targets: _________________________________________________
Integration challenges encountered: _________________________________________

Prescriber Assessment

Medical tolerability: ☐ Good ☐ Fair ☐ Poor (specify): ________________________
Dose adjustments made: ☐ No ☐ Yes (specify): _______________________________
Medication changes: _______________________________________________________

Next Phase Decision:

☐ Continue acute series (additional sessions: ______)

☐ Transition to maintenance schedule (frequency: _______)

☐ Pause KAP / continue integration therapy only

☐ Discharge from KAP

☐ Refer for higher level of care

Rationale: __________________________________________________________________

Signatures

Prescriber: ___________________________________ Date: _____________

Therapist: ____________________________________ Date: _____________

Protocol · Appendix C

Communication Log Template

Date	Time	Method	Participants	Summary	Decisions Made	Follow-Up Required	Logged By

This protocol is intended for use within an integrated KAP clinical practice. It should be reviewed annually and updated as practice standards evolve. All providers are responsible for familiarity with and adherence to this protocol.

Version 1.0 · For Internal Clinical Use

20	hours of observation (watching experienced KAP therapist conduct preparation, medicine, and integration sessions)
20	hours of supervised co-facilitation (co-therapist role with an experienced KAP therapist present)
10+	hours of individual supervision reviewing your cases
10+	hours of peer group consultation