Beyond the Medicine: The Psychotherapy of KAP

If you ask most people what happens in ketamine-assisted psychotherapy, they will describe the medicine session. The couch or the mat, the eye mask, the music, the altered state. It makes sense, because that's the part that is most dramatic and most different from anything else in mental health care. But it's also, in my view, only one part of the work, and not necessarily the part that does the most to change a person's life.

I had the chance to dig into this in a follow-up conversation with Chad Franzen of Rise25, who once again flipped the script and interviewed me. Our last conversation focused on somatic tools and the therapist's presence. This one went further into the principles that shape how I think about preparation, meaning, and integration, and I'd like to share the heart of it here.

Preparation Is Treatment

One of the phrases I use most in trainings is preparation is treatment. In a perfect world I would rename preparation altogether, because the word implies we're simply getting ready for the main event, when the medicine session is really just one piece of a larger process. You can have a profound, even life-changing experience with a psychedelic medicine and it still isn't psychedelic-assisted psychotherapy. That isn't a judgment about the experience, which might be more powerful than anything someone gets from years of therapy. It's simply that psychedelic-assisted psychotherapy, as I practice and teach it, means preparation, the medicine session, and integration working together.

When I say preparation is treatment, I mean that the treatment starts the minute a client is in contact with me. We're working in a relational, trauma-informed way, which means creating safety, being transparent, working ethically, and answering questions honestly. Many clients have never experienced that kind of care before, with other providers or in life more generally. The goal is for them to feel safe with me, safe in the medicine session, and ultimately safe in their own lives.

Getting to Know the Person, and Letting Them Know You

I do three to five preparation sessions before we ever go into a medicine session. I was trained psychodynamically, so I take an extensive developmental history. I want to understand how a person's history has shaped who they are in the world, how their sense of self is organized, and what adaptive or defensive strategies they developed along the way. I want to walk into the medicine session with a working hypothesis about all of that.

It runs in both directions, though. I want clients to feel that I get them, and I want them to have a real sense of who I am and why I work the way I do. Informed consent lives here too. That includes conversations about proximity and touch, which can be as simple as how close I sit. We practice it together, we explore what it feels like, and we make sure the consent is real. Exploring those choices is itself an intervention, because many clients have rarely been given much choice, in life or in previous medicine sessions.

Teaching Skills Before Clients Need Them

I believe deeply, down to my toes, that working somatically is critical to this work. Many of my clients, particularly those with complex or developmental trauma, have disconnected from their bodies. At some point, when the nervous system was signaling danger, disconnecting was adaptive. It was how they got through. So asking someone to simply notice what they feel in their body isn't enough. Connecting to the body can actually feel aversive at first, so we teach just enough of the why, and build awareness gradually, layer by layer.

We also practice grounding into the mat or the chair, and basic tools for choice in the moment: do I want to move toward this or away from it? Can I pause? Can I drop further in? These are mindfulness-based and trauma-informed skills, but they're not only for the medicine session. They apply equally to ordinary life, and we start drawing those threads from preparation to medicine to integration to everyday living from the very beginning.

Observer Mind: Standing Next to the Pattern

One of the things that often emerges naturally is what I call observer mind. It's the ability to stand next to a pattern, a symptom, or a part of ourselves and look at it without being fully engulfed by it. In IFS terms, it's having a bit more Self energy. A client of mine recently noticed that a heaviness they were feeling was just tiredness, not depression. Before this work, that tiredness might have automatically pulled them into a depressive state.

That capacity changes how people relate to their own stories, too. When we can witness a memory or a pattern with some mindful presence, the story we've carried about our role in it can sometimes be seen differently. We anchor those shifts somatically, so they can be accessed again later. It's a healing tool for deep issues, and it's also simply a life skill. If a colleague activates you at work, you can notice it, name it, and ask what you need to come back to a more resilient place.

Letting Clients Find Their Own Meaning

The longer I've practiced, the more I've realized that we don't actually have the answers, and we don't need to. I've been licensed at the doctoral level since 2003, and one of the most freeing things I've learned is that I could simply be wrong about what something means. Insight is useful, but it doesn't always point toward what to do next.

That doesn't mean sitting passively. I'm joining, co-creating, asking questions, and tracking body language, emotion, and the energy in the room. I use deepening prompts and reflect what I'm hearing. A client once described being in a canyon by a river, not sure why. I simply reflected it back and stayed curious. What's the canyon like? Is any part of you wanting to stay or to leave? I'm tracking the content, the emotion, and the felt sense, but I don't need to decide what it means. If I get attached to thinking I know, I close myself off from noticing what's actually unfolding. The meaning-making can come later in integration. And when a client has come in specifically wanting to work on something that hasn't surfaced, I ask permission in preparation to bring it up directly, so choice stays with them.

Process Is Information

How a person moves through a psychedelic experience tells me as much as the content does. Some clients drop in immediately, unbothered by hallway noise. Others hesitate even after thorough preparation. Some begin to drop in and then pull themselves back out partway through. None of that is right or wrong, but all of it is information, and I get curious about how the same pattern might show up elsewhere in their lives.

This comes in part from my background of more than 25 years in experiential education and outdoor-based therapy, where the way someone engages with a ropes course or a hike often reflects how they engage with life. The same parallel-process lens applies here.

Holding Both: Distress and Well-Being

Years ago in a yoga class around the holidays, the instructor asked whether we could be busy but not stressed. It stuck with me. Can we hold some things that are hard alongside some things that are okay? That's not the same as counting your blessings. It's a nervous-system skill.

In a session, I might notice that a client is crunched up with their shoulders near their ears and reflect that back. If they get stuck looping, I might ask what else they notice, perhaps in their hands, or something neutral or pleasant. We pendulate, as it's called in somatic experiencing, moving between the tightness and the settling and noticing that both can be true. In integration we name it explicitly. This is especially valuable for people managing chronic stressors that won't resolve with one insight. One important caveat is that it only works once safety has been established.

I also believe in resourcing as intentionally as we explore distress. Orienting toward what brings pleasure or neutrality, whether it's a pretty yellow flower in a session or the trees outside my office window, helps the nervous system settle. Biologically, anxiety is the default, so we actually have to train ourselves to tolerate well-being. Psychedelics can open that door, and deepening into well-being often gives us more permission to process what we've defended against.

Developmental History as a Compass, Not a Script

I think of early experience like a brick wall. If the foundation is laid with safety, later experiences build cleanly on top. But at some point, often in ways that never look dramatic from the outside, a child's nervous system may register that things are not safe. Being teased, struggling to read, feeling unseen. We develop strategies to cope, and those strategies can become patterns later on. In object relations terms, we internalize what the world reflects back to us, and it becomes our sense of self.

So I'm listening for those developmental disruptions and relational patterns. But the history is a compass, not a script. It's always a working hypothesis. It points us in a direction without telling us what will happen, and our job is to create new, corrective experiences and anchor them in the body so that change is lived, not just understood.

From Insight to Integration

Insight is great, but the question I keep returning to is: what are you going to do with it? A common realization in this work is seeing that someone who hurt us was also shaped by their own history. That's meaningful. But does it change anything? If we can bring it into mindful awareness and into the body, it can become self-compassion. Can I soften toward the version of me who was doing the best they could with what they had? That softening, anchored in the body, is what carries into daily life. This draws on the work of Kristin Neff and of Dr. Ron Siegel, with whom I've been fortunate to work.

In experiential education we talk about the what, the so what, and the now what. Unless insight becomes a felt, lived shift, people can spend years chasing the next realization. My very first ketamine client once said, I know there's something else I'm supposed to realize. That's where one of my favorite phrases comes from: suspend the need to know. We don't always need an answer. We stay curious and trust that what needs to emerge will.

In integration, we look for lived experiences of seeing ourselves differently, we go through the notes together, and we anchor what resonates. I often work with the idea of expansion and contraction: what does it feel like to move through the world in a more open state versus a more guarded one, and how safe does it feel to be vulnerable? Then we ask how someone wants to carry it forward.

That, to me, is the psychotherapy in ketamine-assisted psychotherapy. If you're a clinician who wants to learn this work, you can find out more about our trainings at livingmedicineinstitute.com.

With care,
Dr. Sandy Newes