When Ketamine-Assisted Psychotherapy Is Not the Right Next Step

Not every client who is suffering is a good candidate for KAP. Discernment matters. Timing matters. Safety matters.

Some rule-outs are medical and non-negotiable. Intranasal esketamine, for example, is contraindicated for people with:

• Certain vascular conditions

• A history of intracerebral hemorrhage

• Hypersensitivity to ketamine

Ketamine can also cause transient increases in blood pressure, which means cardiovascular risk must be taken seriously and screened medically.

Other cautions are psychiatric. Most programs treat the following as contraindications or situations requiring very specialized care:

• Active psychosis

• Primary psychotic disorders

• Uncontrolled bipolar disorder or mania

• Uncontrolled substance use disorders

There are also many situations that are not permanent “no’s” but rather “not yet.”

These include:

• Acute suicidal crisis requiring higher level of care

• Ongoing domestic violence or unsafe environments

• Severe dissociation that is already destabilizing

• No plan for preparation, integration, or follow-up therapy

In these cases, the work is stabilization. KAP may become appropriate later, but not before a basic container exists.

Ethical referral means holding four questions:

1. Is there a strong clinical indication, such as treatment-resistant depression or entrenched stuckness?

2. Are there medical or psychiatric risks that require caution or rule-out?

3. Is there a real plan for preparation, integration, and continuity of care?

4. Do we have a way to evaluate whether this is actually helping?

If any of these remain unclear, consultation is not a failure. It is good practice.

One of the risks in the current cultural moment is that ketamine gets framed as either a miracle or a menace.

Neither is accurate.

Ketamine is:

• A tool

• A powerful one

• A limited one

• One that can help some people profoundly

• And is not right for others at all

When we refer thoughtfully, we are not outsourcing our work. We are expanding the field in which our work can take place.

If you have a client you are unsure about, especially around:

• Bipolar risk

• Dissociation

• Substance use

• Medical complexity

You do not have to decide alone.

Therapists, you can reach out through the Starks Therapy Group contact page if you have a referral you want to think through collaboratively.

Sometimes the most ethical answer is not yes or no. It is, “Let’s think about this together.”

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Autumn Starks is a Licensed Clinical Social Worker (LCSW), Internal Family Systems Certified IFS Therapist, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), special interest in Complex PTSD and other disorders resulting from religious trauma and spiritual abuse, Certified in Psychedelic Assisted Psychotherapy through the Integrative Psychiatry Institute, and is the founder of Starks Therapy Group in Oak Park, IL where she partners with Richard Clark, CRNA, APRN, to provide ketamine-assisted psychotherapy and they host together the Ketamine Collective for therapists.

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