Cognitive Ketamine Therapy for Trauma
I found a weird way into the therapeutic world. While many new therapists may approach entering this field from agency work, I started with research and psychedelic work, and eventually found my way into an agency.
A psychedelic experience, almost 10 years ago now, lead me to change my major from Mechanical Engineering to Psychology when I was only 20 years old. I spent a long time gaining research experience in hopes of getting my PhD, but the PhD dream later fell by the wayside when I finished up my Master’s in Addiction Counseling in Psychology and had a baby. I had to settle down and focus on my family and financial stability.
I got my LPCC and ADDC statuses in Colorado, opening the door to practicing therapy. I quickly started a private practice, needing the flexibility that I knew was offered by private practice, as well as higher earning potential. Without much clinical experience at all, I fell flat on my face.
My internship was mostly focused on ongoing research work with psychedelics, working on high-profile clinical trials like the MAPS MDMA-assisted therapy for PTSD trial, as well as the MindMed LSD for Generalized Anxiety Disorder Phase 2b study. I was able to get my ketamine-assisted therapy training during that time as well.
Steeped in the psychedelic world, I felt prepared to guide people through ketamine-assisted therapy. However, I came to learn that I was really lacking some basic therapeutic skills outside of ketamine work. I knew about Motivational Interviewing as a foundational technique, but not much more than that.
I eventually found my way into an adolescent residential treatment center, needing to make a paycheck and needing to gain some foundational skills. I took required trainings: SMART recovery, DBT, and TF-CBT. These started to give me some therapeutic tools that I didn’t have before.
However, the adolescent residential work came to a halt after about 8 months, as I experienced issues within the organization. I switched roles into an outpatient community mental health role with Summitstone Health Partners, where I have now been for 3 months.
I was initially slow to build a caseload and struggling to find my clinical style. In my struggle, I found a training in Cognitive Processing Therapy (CPT). CPT is an adaptation of Cognitive Behavioral Therapy for PTSD. While I thought I might not like something super structured with a lot of worksheets, homework, and a set number of sessions, I was really intrigued. I started learning about and implementing this intervention in my clinical practice with PTSD clients and it’s been really effective so far.
The thing is, when you come from the psychedelic therapy world you often hear these thoughts thrown around saying that our current treatments for PTSD are ineffective, and we need more effective ones. While I don’t disagree that we have a huge burden of trauma and a need for access to care, I was surprised when I dove into the research and found out how effective interventions like CPT and exposure therapy are.
For reference, 65–86% of civilians may lose their PTSD diagnosis after trauma-focused psychotherapy.
However, I do think there is a lot to say about psychedelic therapies for treating multiple diagnosis, overall healing, and more heart-centered, relational therapy.
Which got me thinking… what if we combined CPT with psychedelic treatments like ketamine-assisted therapy?
a therapist sitting for a client on ketamine
A Brief Review of 2 Interventions
What might this look like?
Ketamine-Assisted Psychotherapy (KAP) is generally structured in the following way:
3 preparation therapy sessions
1 medical evaluation and prescription session with a prescriber
6-9 ketamine-assisted therapy sessions
6-9+ integration sessions (at least one per ketamine session)
CPT is generally 12 sessions, which focus on using structured assignments, reflection, and psychoeducation to build awareness around “stuck points”. I.e., beliefs one holds about who was at fault for the trauma, views about the world and others, and other beliefs formed as a result of the trauma. These stuck points are often “black-and-white” or “all-or-nothing” and leave no room for nuance.
The goal of CPT is to identify these stuck points, and systematically work to challenge and reframe them. Essentially, you’re looking to help the client form new neural pathways around their trauma, which allows their prefrontal cortex to help downregulate the fear response that’s overactive in the amygdala.
Ketamine is a known neuroplastogen, meaning that it’s been shown to make the brain more “plastic”, i.e., it helps the brain learn new information easier and break out of previously ingrained patterns.
So, how might these two interventions support one another?
The Benefits of Combining KAP + CPT
I believe a combined intervention, where the client is able to go inward, reflect on their experiences surrounding trauma under ketamine, and then work with their stuck points would be highly effective. We can consider taking advantage of the neuroplasticity of ketamine, as well as the unique opportunity to access one’s subconscious mind, step out of one’s body, and have an entirely different perception on past events.
Combined this with structured cognitive exercises would allow a client to pull previously held “stuck points” out, and then work with them while in a more plastic state. Additionally, a client could be supported by their work in CPT where they practice challenging stuck points.
At the start of the CPT intervention, clients identify stuck points using “ABC” sheets. This works by looking at an event that happened, what stuck point might be related, and then how it made them feel. They then ask if this stuck point is realistic and/or helpful, and what might be a better thought.
I have one client that’s been doing this every day for two weeks, and he reported that he’s better able to analyze how he’s feeling, and find the cause for it. Essentially, he is building muscle memory around identifying stuck points!
So, being able to utilize ketamine could leverage this muscle memory by ingraining it deeper, but also giving clients a more reflective look at the stuck points and how they’ve begun to analyze them.
A Proposed Session Structure
Because I’m still completing my CPT training and implementing it with clients, I don’t yet have a full proposal, but here’s somethings we might consider in terms of structuring the intervention.
Session 1: Identifying trauma through PCL-5 assessment. Confirm the diagnosis. Explain the intervention, work through barriers, and explain KAP.
Session 2: Continue KAP psychoeducation and preparation. Explain the avoidance cycle of trauma, and introduce the first CPT assignment: writing a one page essay on why the trauma occurred and how it has affected the client’s worldviews (this starts to identify stuck points).
Session 3: Explain stuck points, review the essay, and begin building a stuck point log. Address any outstanding concerns about ketamine and refer to a medical provider for evaluation. Assign the 2nd homework exercise, one ABC sheet per day.
Session 4: Review ABC worksheets, settle the client in, and then have client self-administer ketamine. Integrate and process, and then assign the next 7 ABC sheets on trauma.
Session 5: Integrate the last weeks ketamine session, review past 7 ABC worksheets.
Technically at this point you could just rinse and repeat this cycle and it’d probably be highly effective. However, CPT does have structured psychoeducation and homework assignments, so it would be wise to continue using these. These worksheets are essentially expansions of the ABC sheets, and they work to challenge the stuck points in more detail.
Conclusion
CPT has been shown to be highly effective at treating PTSD, but the trauma burden is still not met. Because CPT works to rewire neural pathways, and ketamine is a known neuroplastogen, the combination of these two interventions could be highly effective in the treatment of PTSD. Related conditions, like depression and anxiety, could also be future areas of exploration. However, much is still now known from a research perspective about ketamine-assisted therapy, and the current literature mostly focuses on ketamine injection therapy which critically lacks the therapy component. Adding therapy helps clients integrate insights, whereas ketamine injection therapy effects generally wear off and require maintenance. Combination therapy with a structured, effective trauma treatment would likely increase effectiveness and durability of effects long term. Ongoing work in this area is warranted.
About the author:
Cole Butler, LPCC, ADDC, MACP
Cole Butler, LPCC, ADDC, MACP is a Mental Health Therapist and Writer. He co-founded Integrative Care Collective in 2023 to support mental health providers that are passionate about integrative care and to foster community amongst them. You can learn more about and connect with him on LinkedIn: https://www.linkedin.com/in/cole-butler/
