Ketamine-Assisted Psychotherapy for Trauma: Some Healthy Debates

Trauma therapy is a complex and often debated field, with professionals holding differing views on the best approaches. Some therapists prioritize exposure, helping clients directly engage with painful memories, while others focus on resourcing to build a sense of safety and well-being. When ketamine is introduced into trauma work, how does it shape the healing process, and what approach leads to the most effective outcomes?

Psychedelic therapy training professionals Dr. Signi Goldman and Dr. Sandy Newes and training students Barbara Connold, Barrie Bondurant, and Amy (Maiima) Nicholson explain that ketamine-assisted psychotherapy facilitates a balance between exposure and resourcing. Clients often toggle between processing traumatic material and deepening into states of well-being without direct therapist intervention. During ketamine-assisted therapy sessions, therapists should practice tethering to ensure clients feel supported, manage disassociation as a therapeutic tool rather than a barrier, and assess a client’s readiness for deeper trauma work. Dr. Goldman, Dr. Sandy, Barbara, Barrie, and Amy also underscore the importance of preparation and integration, ensuring clients develop resilience and maintain stability between sessions.

In this episode of Living Medicine, Dr. Signi Goldman and Dr. Sandy Newes interview Barbara Connold, PMHNP, of Ketamine Psychotherapy Associates, Barrie Bondurant, PhD, LC, and Amy (Maiima) Nicholson, about the intersection of ketamine and trauma therapy. Together, they share insights on managing client dysregulation, the relational aspects of ketamine-assisted therapy, and strategies for balancing exposure with resourcing.

This episode is brought to you by the Living Medicine Institute.

LMI is a training, resource, and membership program educating providers about the legal and safe use of psychedelic-assisted psychotherapy.

To learn more or participate, visit https://livingmedicineinstitute.com.

Intro 0:00

Welcome to the Living Medicine podcast where we talk about ethical medical use of psychedelic psychotherapy, teaching skills, examining the issues and interviewing interesting people. Now let’s start today’s show.

Dr. Sandy Newes 0:19

Hi. I am Dr. Sandy Newes and I’m here with Dr. Signi Goldman, my business partner, and we are the Living Medicine Institute lead trainers and co-founders, and we’re going to just do a brief kind of discussion about the use of ketamine for trauma. This is something that we regularly get asked about in our training programs. And there is a prevailing view in the field of like, one, it’s not used for trauma. Or two, it’s used in this particular way for trauma. And one of the things that’s really interesting about that I have found Signi, as you know, in our collaboration, is you and I do trauma work really differently, and yet, I think we’ve influenced each other over the years to where maybe it’s not as differently, different anymore, maybe it never even was, but, but, you know, we come from different frameworks and around what is effective, what works, and so we just want to kind of have a little bit of a discussion about, you know, some of those different perspectives. You know, we’re going to move more into in future podcasts kind of about more kind of how to’s and what to do, but let’s kind of just stay on that macro level for right this moment. 

Dr. Signi Goldman 1:31

Yeah, we get asked this a lot, and there’s the question of our different backgrounds. You come from, you have a more somatic background. I have a more of a exposure therapy kind of background we I have a psychodynamic background. You also have trauma and resilience background. So like we have these different, you know, things that our careers have brought us through leading up to this work. There’s that, but then there’s this question that comes up because we work in psychedelic world, and we run training programs of, how does one do trauma work on ketamine, new variable, and the ketamine itself affects the way people process trauma. And so there’s been these, like, really, you know, kind of funny, interesting conversations that we’ve stumbled like, we keep stumbling into over the years, of like, well, you know, I have my skill set for how to do trauma work, but on ketamine, people go in this direction, or this happens, and you have, you say the same, and then our trainees are often like, what are you guys doing that’s the same, versus what are you guys doing that’s different? And so we’re gonna, you know, open up this particular podcast in a few minutes to questions from actual trainees who volunteer to come on and just kind of talk this through or hash this out. But I think maybe a nutshell version is we get a lot of questions about how much one can do exposure work. You know, which by what I mean by exposure, loosely, for this conversation, is people sitting with the trauma, people being present with flashbacks or even intentional, like prompted exposure work versus how much you work with creating resilience or resourcing people intentionally, or increasing their ability to tolerate well being, which is a thing I hear you say a lot. The phrase growing the good, I think you use a lot.

Dr. Sandy Newes 3:22

I got that from Rick Hansen, you know Buddha, yeah.

Dr. Signi Goldman 3:25

We all got things from somewhere, yeah. But it’s interesting, because our trainees will say, Wow, both of you guys are full time cat providers, and both of you guys work with trauma, which is true, are you doing the same thing? So that is, do we think we’re doing the same thing?

Dr. Sandy Newes 3:41

I think now we are doing much more of the same thing than we were in the beginning. Which I find interesting is that something that kind of we taught each other, we influenced each other. Is that a natural progression of things? 

Dr. Signi Goldman 3:54

Well, this is where the conversation gets kind of funny. Is that we don’t sit in in each other’s sessions. So if you sort of watch me and I don’t watch you. We have, we have videos like, we’ve seen each of those video sessions, but we’re not, you know, we’re not really in each other’s practices like flies on the wall. And so this really has to become a conversation like, well, what are we doing? Because, and this conversation just comes up because we train people. So as you guys, as you listeners, can tell we’ve had this conversation before, and we’re just kind of having it in a public forum because it’s super interesting. And I mean, I the working theory that you and I’ve tossed back and forth is that what we’re doing may look more similar to each other these days, not so much because we have taught each other anything, but because the ketamine steers it in that direction, you know, and I think just to put that more succinctly, if you are a therapist that you know emphasizes more resourcing or resilience, ketamine does facilitate resourcing, or a sense of well being and working. If you are. Therapist that does exposure work, you know, quote, unquote, like I’m not using that, I’m using that in a in the sense that I mentioned earlier. Ketamine can facilitate that going better than it does in kind of ordinary awareness. But what the ketamine? If I can just anthropomorphize it for a second, really seems to want to do is to toggle people back and forth, right for sure. So if you go in just with an exposure lens, my experience, and that would be a mistake to do that. But if you you know, I may have had that bias more in the beginning. If I you know, if you go in and just with that lens, it’s almost like the ketamine will will, like, I don’t want to say force, will nudge you, as a therapist, towards the fact that the client wants to resource, or is starting to resource spontaneously, and then you follow that, right? And I’m curious, if you go in with just a like, if your lens is more about resourcing and well being you and I have talked about, does the ketamine and the client on the ketamine almost instinctually toggle themselves towards what I would call exposure work? Yeah, is the ketamine, if we can think of it that way, trying to get us to do both?

Dr. Sandy Newes 6:16

Yeah, I mean, that’s honestly what it feels like to me, is that and that, you know, what we’re doing is kind of following the threads. One thing that I find useful in my work is that I do educate about resourcing and the importance of growing the good prior to doing the work. Because sometimes clients will be like, Wait a minute. Am I just like, high and feeling good? I thought I was here to do, you know, really hard things and really on a nervous system based level, especially with somebody with complex trauma or chronic stress and anxiety, or really any chronic mental health condition. You know, the ability to notice, tolerate and sit with well being is a very relevant clinical outcome, to be able to feel safe, feeling better, and so, you know, so, so it’s not just that we’re like moving towards feeling better, it’s that we’re moving developing safety and feeling better, which is one of the artifacts of trauma. And you know, one of the things that I had been drifting away from in my traditional clinical practice prior to us working together, is actual processing of identified index traumas, right, which is harder when you’ve got Complex PTSD, because it’s sometimes harder to get that the thing. And now I notice that naturally emerges. And so this toggling that is really pendulation, that really comes out of somatic experiencing, happens naturally, so we can just work with it, and it’s just there, like, so working with that with intention is, you know, I love what you said about maybe just the ketamine itself is bringing us closer together, because that just naturally seems to happen, which then begs the question about how much we’re actually making it happen. But that’s, again, how do we know that?

Dr. Signi Goldman 7:59

Well, that’s, you know, I’ve thought about this, and that comes to this whole thing we teach, and we’ve experienced it this non directive approach, and the idea being that what needs to happen for the client is what’s going to happen. And we are not, we are actually teaching people not to prompt or steer. So we neither you or I, kind of steer the session. That’s a big part of our ethos and what we teach, but in the beginning, especially, I think there was this curiosity, and it’s a good learning it’s a good teaching point does, because we have a certain lens. Are as my are my clients, having more type exposure, type experiences, because I just have that lens. And are you? Are yours having more overt kind of resilience, resourcing, focused experiences, because you have that lens, even though we’re not intentionally steering them. That was one of the early conversation. The early conversations we had. Well, that’s interesting, like, that’s a good thing for us to track and especially and to teach trainees about. And as we were both being curious and making an effort to be non directive, you know, I remember us, you know, talking a couple times, you know, over the years about noticing that the client’s nervous system on ketamine. Or maybe you could think of it like the ketamine itself knows this. But something about the client and the altered state, whatever that that wisdom state, that that they are, that unconscious guidance that they have, wants them to do both, like I think people that I think healing looks like some sort of processing of fear content in a safely held way where they have agency and collaboration and some sort of sitting with and anchoring in a new sense of resource. And those two things that the sessions, the trauma sessions, I’ve seen, you know, over the years, is like, you know, if you think you’re going to go one direction, you but you may for a while, but eventually the client will just spontaneously go the other direction. And so I’ve learned, in a way now, to just expect both and to have languaging and sort of, you know, like intentional ways of working with both. But I feel like this is just me. I’m curious what you think I feel like. If I do a whole session that’s kind of exposurey, just to be informal, the last part, like right before the tail, the client will just drop right into some sort of resourcing thing, whether I say anything or not, and then I’m just kind of mirroring that. They just automatically do some sort of inner guidance does that. And I’m curious if the opposite is true.

Dr. Sandy Newes 10:21

No, the opposite is a little bit true. Um, but it, you know, then, I mean, at that point, then we look at the parallel process, about, to what degree does somebody use? Like, oh, let’s just look at happy things in our life and avoid, you know, looking at the hard stuff. Like, how much of that is already is happening for them already. Like, what are their defenses around going to the thing? So I think when you do a lot of emphasis on resourcing and well being, that you also have to be more intentional about holding the client’s intention. Like, is there added benefit in processing hard, you know, traumatic event and traumatic material directly in kind of an exposure piece. And if it doesn’t naturally emerge, and you’ve done several sessions, which I often do series, then I do prompt them more like so, you know, I’ve noticed that we haven’t really processed some of that stuff.

Dr. Signi Goldman 11:15

And why do you do that? Like in your because

Dr. Sandy Newes 11:19

I have found that there is tremendous value added in doing it for some people. But even then, I still won’t push it. I’ll just prompt it a little more, like, you know, I might say, like, hey, so I’m going to bring this up when we’re, you know, a third of the way in, just to see if it’s like, we naturally go there, and if the psyche doesn’t naturally go there, then I’m not going to push

Dr. Signi Goldman 11:39

it. Right? Yeah, I mean, pushing anything, it would be kind of unethical and in a psychedelic context, at least the way that we teach, right, right? Which is interesting, because i That’s why we’ve always been so curious. Like, why do my clients tend to have more exposure type stuff, if we’re neither of us is pushing anything? Is it because, like, it’s so fascinating, right? Is it because I have that background, like something about the way I just use words, or I language things, but it may also be the way I talk in preparation, because I think I may front load in preparation, the possibility of that, and maybe that is why it spontaneously happens for people, and it’s just something to be it’s just interesting. Yeah,

Dr. Sandy Newes 12:17

I mean that said I have done things based on your influence somewhat differently. You know, as a result, where I have had more sessions where a client has come in, like, fully prepared to process, like, the thing, and we just do that because we start with that, and I so that is more directive, like, but, you know, meaning, but there’s a shared agreement that it’s a collaboratively developed, shared agreement that that is what we’re going to do, which is really different than material that sort of like, you know, it’s lurking there, and you’re kind of looking for the place where it might emerge, and then it does emerge. Those are two different kind of ways to approach a session. And I do more of the former now than I might have initially, probably because, yeah, I

Dr. Signi Goldman 13:02

think one thing I would name before we close this, just as a kind of interesting summary and a LIKE TO BE CONTINUED statement, is, there’s, ooh, how can I, how can I best language it? I think that, first of all, these are controversial topics. There are many people out there, many of you even listening with very strongly held opinions about how trauma work should be done period, and how it should be done on ketamine also. And there are camps. There are camps in trauma world, and they don’t always agree with each other, and some of them think that the other camp is doing harm. So they realize this this is like, you know, swirly waters here that we’re wading into. And yet, it’s important, because we run a training program, to think about it, and we do trauma work ourselves a lot. And, you know, we have to be transparent about the fact that this is a nuanced and evolving conversation, and how do we do it best? And that’s, you know, that’s what we’re trying to do. That being said to me, like, the two things that arise are, there’s a bias in some types of trauma work to under resource people, or there’s a concern, oh, you’re not resourcing like you’re just putting people, yeah, they’re facing their fears, but they’re not learning how to resource, right? They’re not learning how to regulate, and you’re dysregulating them without, you know, in a way that is not therapeutic. And that, from that camp, you would say, do less exposure and do more resourcing, and that even on ketamine, right? And then there’s another line of thought

Dr. Sandy Newes 14:34

associated to like, oh, they say they’re getting better, but actually they’re just dissociating. Right?

Dr. Signi Goldman 14:39

Are you just making people dissociate. This is another really valuable line of inquiry, especially with a with a when you’re putting it dissociative, psychedelic in the picture. So this is a really rich conversation. And then there are more than just two camps. But to oversimplify, I would say there is a another camp that has maybe been more the world that I came up in. I. Which is, to what degree resourcing and regulating can just become avoidance or or, you know, where does that happen? Right? And is that what people are already doing too much of right themselves, and are we just furthering that? And so it’s this fascinating place where I think we’re doing the right thing right now by just asking the questions and having this conversation openly with trainees who come from many different backgrounds themselves. And I think it’s a it’s also a waters that the whole field collectively needs a weight into talking about more. So we plan to have a lot more podcasts talking to trauma people and people doing trauma work. Because it is, you know, it’s, it’s tricky territory, but it’s, it’s beholden on us to go there. And

Dr. Sandy Newes 15:47

I want to add one more piece that I just find in very deep emerging interest, which is, again, and I don’t think that this is not the same as resourcing. This is like just a track that emerges in psychedelic work about deepening into well being, and kind of how that impacts the default mode network like, and can we be more intentional with that? And is that trauma work like, you know? So to be continued. Yeah,

Dr. Signi Goldman 16:12

To be continued. And we will have some trainees coming in ask us some questions that, especially about this stuff, and let’s just see how we field it together and make it like an ongoing conversation. It’s good stuff. So Sandy and I are joined right now by some of our trainee community. We have Barry Bondurant, who’s a licensed clinical mental health clinician from Asheville, North Carolina. We have Barbara Connold who is a board certified psychiatric mental health nurse practitioner, and she runs a psychiatry and ketamine treatment clinic in Greenville, North Carolina. And Amy Nicholson, Amy Maiima Nicholson, somatic psychotherapist and shamanic practitioner from Madison, Wisconsin. So we really appreciate you guys joining us initial thoughts or questions, and we’ll just hash out anything you guys are curious about,

Barbara Connold 17:03

I do. So, how would you manage a person with complex trauma who’s not well resourced and becomes dysregulated and dissociate? 

Dr. Signi Goldman 17:15

You want to go with that one, or you want me to take it? Yeah.

Dr. Sandy Newes 17:18

I mean, I personally, really strongly believe with complex PTSD that we need to do a lot of education on the front end. For me, preparation involves educating about what happens with complex trauma and what happens with the nervous system. It involves teaching somatic skills, helping people connect to their body, and also some basic mindfulness prompts. So connecting somebody as they move in, we practice it in preparation and do it in the chair as a starting point to help them connect different parts of their body to the actual chair. So when somebody in a session begins to dissociate or becomes dysregulated or gets lost and doesn’t know where they are and gets into a fear response. I’m first gonna go to that, but that’s assuming that I’ve already taught them that if I have not for whatever reason, then I’m going to orient them to the room, so I might remind them of where they are. At times, you might even have somebody lift up their eyes shades and look underneath if they’re really panicky, so that they know I remind them of my presence. If I’ve already done consent around touch, which I do all the time, which I think is critical, then I use touch, and I might use touch on their arm, or I might use touch on their chest. If I have consent, I may also have them touch their own legs or touch their arms. This, these are my legs, these are my arms, and have them connect, notice the sensation and speak those words out loud. So really, some very, you know, intentional grounding. And from that perspective, it’s not that much different than when somebody dissociates or becomes really dysregulated in the actual session. And again, that’s also assuming a fairly high level of distress like and that’s getting in the way of their ability to process and to move through the session. So if they’re if they’re just kind of not, if they’re more blank or more dissociated, or I don’t know where I am, or I’m not sure what’s happening, that’s kind of a different piece around using deepening props and being really curious about exploring where it is that they are. So, you know, it’s almost like which level of activation are we looking at? Kind of like the low zone, you know, the shutdown, the loss, the disconnected, or is it more in a state of activation that? And in that case, you know, we also are tracking the IV carefully, because sometimes people might start moving, um. Um, and, you know, helping them kind of orient and ground themselves in space. That’s really, to me, that’s really different than actually working with the state that’s helping somebody through that more acute piece. Thank you.

Dr. Signi Goldman 20:15

Are there other curiosities you have about that, like, if the how to handle people who are dysregulated or does that bring up any other questions? It does.

Barbara Connold 20:23

I just remember a client who became more dysregulated in between sessions. And you know, I really appreciate you balancing the exposure therapy with no somatic kind of work. But when somebody is not well resourced, you know, it can be challenging as well.

Dr. Sandy Newes 20:49

Yeah, teaching somebody how to resource prior to going in, I think, is of critical importance. And resource can look like a lot of things, yeah, like going outside and sitting on your porch. It can look like sensing in, you know, to a moment or something that makes you feel good. It can mean, you know, petting your cat or your pet. It can mean, you know, awareness of some self care skills and the importance of doing it a lot of times. What I believe is that when people also expect what’s going to happen. So helping somebody understand that sometimes things actually might get worse before they get better is often a really, really useful platform, and that’s really, again, analogous to more traditional psychotherapy too. When you do trauma work and people go deeply into, you know, some of the painful material that they’ve been guarding against or have been well defended by, sometimes people do become more dysregulated, or they go into a dissociative state and and sometimes they have a hard couple of days, right, or hard weeks like sometimes the only way out is through. So helping people really understand that this is not a linear process. In fact, when I do a lot of I do a lot of infusion series, and it’s pretty predictable that around you know, between session three and four, people are going to start to think they’re getting worse. And so when people understand that that’s a prior to the process, and you kind of front load it, you don’t say this will happen, but you say this could happen, and that’s actually might even be a good sign. So then people have a lot more faith in what you’re doing.

Barbara Connold 22:24

I appreciate that. Thank you. I definitely

Dr. Signi Goldman 22:26

agree with talking about the possibility of this happening in preparation. And then there’s this obvious maybe piece about knowing your client. I feel like usually the people that I’ve had that have become the most dysregulated are the ones I suspected would because of what I know about their their psychopathology, or their particular trauma patterns and and one way that you can pre empt that just as a technique ahead of time. It’s not always, you know, fail proof, like it doesn’t always work, but I’ll if I suspect someone is going to become more dysregulated because they have a certain more, a certain fragility, or something shows up in their symptoms that make me you know that I see a pattern there. There is this exercise that you can do in your first session where you take the entire first session just to get them comfortable with navigating deepening or lightning the medicine. Obviously, that’s easier on an IV, but you can do it on any route, because you what you do is you put them on a relatively lowish dose, and you tell them, all we’re going to do is work on your comfort level and your sense of safety with the sensation of feeling altered. We’re not going to address any content or process anything. So we’re going to put you on this we’re going to first of all check in how safe you feel right now. Right now in your body, and have them really be mindful, really, actually make sure they’re authentically tracking that a sense of safety. And then when they get on the medicine, you have them track like you prompt, notice your safety, notice all the things that you’re doing the safe some some of the similar prompts, Sandy named, and then you can prompt them to lean into the medicine more so they can orient more. Orienting more would be like all the oriented things people do, like touch, contact, tracking the room, trying to talk to you, like Cindy said, touching themselves, sometimes even taking off their eyes shades. And that would be like or being more verbal with you. And then you can have them, do you know, move away from all those things, get quiet or get less verbal, put their eyes shades on deep and in. You can even turn the music up. You can do have them go deep in and let them feel it a little more deeply. And then have them track how comfortable do you feel with that? And now notice that you can lean in or notice that you can lean out. You have to be at the right dose range for this, but if you do that a lot of times, what they’ll do is they’ll they’ll kind of tiptoe in, and then they’ll try to go a little deeper, but then they’ll notice for themselves that they can kind of back back out again. Then they’ll do it again and again, and it creates this sense of safety in them that, oh, I can pace this, and I’m not going to become. Um, like overwhelmed, like falling off of a cliff. And then sometimes I do that as the entire first session, and then in the second session, I have them kind of self titrate the dose up. I’m not saying that always prevents any kinds of fear episodes, but I have found it really useful with people, not all of a sudden, getting shocked or overwhelmed by the altered sensation or something like that in one of the early sessions.

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