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Temenos Center for Integrative Psychotherapy
 

KETAMINE ASSISTED PSYCHOTHERAPY 

 

INFORMED CONSENT

 

Welcome to the Temenos Center for Integrative Psychotherapy. Temenos offers individual, couples and group psychotherapy in conjunction with ketamine administration to support integrated mind, body and spirit, known as ketamine-assisted psychotherapy (KAP). At lower doses, ketamine is used in psychotherapy sessions as it reduces fear and loosens defense structures. At medium-to-high doses, it provides a mind-altering experience that for many people increases the relationship with one’s innate healing wisdom.

 

Please read the following policies and procedures carefully. As a Professional Psychological Corporation, we are governed by certain laws and regulations and a code of ethics. This document includes a statement of client rights and responsibilities, along with important information about our professional services and business policies. 

 

Prior to setting up an initial appointment, please also read the additional information about ketamine’s potential and properties as a medication, as well as the more detailed descriptions of ketamine-assisted psychotherapy. 

 

Your signature at the bottom of this document signifies that you understand and agree with these policies and freely consent to treatment. We will collaborate with you at every step of developing and implementing your treatment. You may choose to terminate treatment or to collaborate with your Temenos psychotherapist to change your treatment plan at any time.


 

KETAMINE-ASSISTED PSYCHOTHERAPY (KAP)

 

Ketamine has a long history of use as an anesthetic and analgesic where it has been used in a variety of medical situations because of its safety. Ketamine is now used off-label in conjunction with psychotherapy to treat depression, anxiety, suicidality and other serious psychological conditions. 

 

KAP is an innovative psychological treatment approach that, within a safe and supportive setting working with one or two psychotherapists and/or physician, includes initial medical and psychological assessments, medicine sessions during which ketamine is administered, and follow-up integration sessions. The exact nature and sequence of the treatment process varies depending on the particular issues being addressed and each individual’s needs and goals.   

 

As treatment progresses we continually assess the effectiveness of your treatment and collaborate with you in determining how to proceed. At the termination of treatment, we review the success of the treatment in having met your goals and develop a plan with you for ongoing support as needed.


 

ELIGIBILITY FOR KETAMINE TREATMENT

 

Our initial session with you will be a Medical and Psychological Assessment, with a licensed psychotherapist and physician. This 90-minute session includes: an evaluation of your current concerns, needs, and goals; a medical history and physical exam; a review of your medical/psychiatric history; and a review of current or past psychological/psychiatric history and treatment; and possibly the administration of brief psychological tests to assess your current level of functioning. Based on the findings in this session, our treating physician may also recommend additional diagnostic testing, including, but not limited to: blood and/or urine laboratory tests, EKGs, or other tests.

 

At the conclusion of this session, we will offer our clinical impressions and recommend an approach to treatment. This recommendation may include specifics in regard to ketamine, including route of administration (sublingual, intramuscular or intravenous ketamine, or intranasal esketamine), or other treatment strategies. We will decide together what might best help meet your goals. 


 

CONTRAINDICATIONS OF KAP

 

Because the effects of ketamine on pregnancy and nursing children are unknown, pregnant women and nursing mothers are not eligible for KAP.

 

Untreated hypertension is also a contraindication because ketamine can cause a rise in blood pressure. Similarly, a history of heart disease may make you ineligible to participate. However, if these conditions are adequately managed, they may not preclude treatment with ketamine.

 

Ketamine is known to interact unfavorably with a small number of medications. Your medication history will be closely assessed to determine your eligibility for KAP.

 

Ketamine should not be taken if you have untreated hyperthyroidism. There have also been reports of some decrease in immune function in patients receiving very high doses of ketamine for surgical anesthesia, typically much higher than what is administered during KAP treatment.

 

Ketamine has an extensive record of safety. It does not affect respiratory functioning at treatment doses. Rarely (in fewer than one out of one thousand cases), ketamine can cause a condition called “laryngospasm” making it difficult to breathe. In the highly unlikely event that this occurs, we will support your breathing, and will likely call 911 for further management.


 

SPECIFICS OF KAP SESSIONS

 

Preparation for a ketamine session requires assessment of your readiness for the experience and the development of rapport and trust between us and you. We will work with you to prepare you to create a mindset that facilitates openness, growth, and transformation. The degree to which we interact verbally will depend on the intentions you set together before the session, the ketamine dosage, and what psychological material arises to work with in the moment. 

 

During the ketamine session(s), you will be asked to make two (2) agreements with us to ensure your safety and well-being:

 

  1. You agree to remain at the location of the session until we decide it is safe for you to leave. 

  2. You agree to follow any instructions we provide to you regarding safety and follow up. 

 

The length of ketamine sessions varies from person to person and from experience to experience. We generally use sublingual lozenges and intramuscular (IM) injections depending on our assessment and your intentions for the session. Sessions typically last from 1½ to 3 hours. 

 

We will determine ketamine route of administration and dosage depending on your prior experience (with it and/or other psychedelic medicines), body weight, and sensitivity. We always begin with lower doses to help reduce anxiety and take the time necessary to become familiar with its effects. 

 

We generally begin ketamine treatment with the administration of sublingual lozenges of 50-100 mg. The lozenges dissolve slowly, and in order to receive the best results, we ask you to let the lozenges dissolve in your mouth for at least ten minutes. Ketamine will penetrate the oral mucosa (lining of your mouth) and is rapidly absorbed in this manner. This will assist us in accurately measuring your responsivity to ketamine.

Following the use of sublingual lozenges, we often move into the use intramuscular (IM) ketamine injections at future sessions. These injections are given in the shoulders or buttocks at a general maximum dosage of 130 mg. This use of ketamine can create an unusual experience of formlessness, the dissolving of boundaries, and novel effects on the mind. Therefore, we rarely begin ketamine treatment with IM injections. During IM sessions, you will be mostly internally focused for the first 45 to 75 minutes. You will continue to remain under ketamine’s influence at a lesser level for at least one hour after that. 

 

For all ketamine sessions we ask that you do not use alcohol or benzodiazepine medications (e.g., Ativan, Valium, Xanax) for the prior and following 24 hours, as this may have negative emotional and physiological consequences, or may decrease the efficacy of the treatment.  

 

We encourage you to ask us questions you may have concerning the procedure or the effects of ketamine at any time. You may withdraw your consent to receive ketamine treatment and/or discontinue your participation at any time until the actual lozenge or injection has been given.


 

EFFECTIVENESS OF KAP

 

As with all medical and psychotherapeutic care, including KAP, there are risks and benefits to pursuing treatment. In general, KAP provides a beneficial adjunct to healing and growth. Most, but not all, people who participate in a KAP protocol find that troubling and often long-standing symptoms are decreased and that life is more satisfying. 

 

While important positive changes in mood, cognition, coping and defense structures are often noted immediately following a KAP session, sometimes effects take longer to manifest, and can happen in the days and weeks that follow.   

 

Individual responses vary widely. It is important to realize that participation in KAP can involve experiencing uncomfortable feelings, engaging in difficult interactions, or being challenged to see the world in new and different ways. It is not uncommon for people to experience painful memories or be confronted with new images of the self. Occasionally, in the process of working through issues, depression or anxiety can temporarily increase before improvement is seen. Occasionally, side effects such as blood pressure increases or nausea may make ketamine use unfeasible.

 

We make no guarantees as to the result of such examinations, treatments, and/or diagnostic procedures. If any questions or concerns about our work together arise at any point during treatment, please bring them to our attention.

 

POTENTIAL RISKS OF KAP

 

You will be asked to lie still during the ketamine administration because your sense of balance and coordination can be adversely affected until the drug’s effect has worn off — generally from two to four hours after the administration. It is possible you may fall asleep. Other possibilities include blurred and uncomfortable vision (you are advised to keep your eyes closed until the main effects have worn off); slurred speech; mental confusion; excitability; diminished ability to see things that are actually present; diminished ability to hear or to feel objects accurately including one’s own body; anxiety, nausea, and vomiting. Visual, tactile and auditory processing are also affected by the medication. Synesthesia — a mingling of the senses — may also occur. Your ordinary sense of time may also be distorted. 

 

Because of the risk of nausea and vomiting, please refrain from eating and drinking for at least 4 hours prior to the sessions. Eat lightly when you do. Hydrate well in that same time frame. If you are prone to nausea, we may offer you an anti-nausea medication — ondansetron — in oral dissolving tablet form.

 

Ketamine generally causes a transient increase in blood pressure and pulse rate. If blood pressure monitoring reveals that your blood pressure is too high, we may offer you clonidine to remedy this.

 

Agitation may occur during the course of a ketamine session. If your agitation is severe, we may administer lorazepam orally or by injection to help you relax.

 

The administration of ketamine may also cause the following adverse reactions: tachycardia (elevation of pulse), diplopia (double vision), nystagmus (rapid eye movements), elevation of intraocular pressure (feeling of pressure in the eyes) and anorexia (loss of appetite). 

 

Driving an automobile or engaging in hazardous activities should not be undertaken until all effects of the medication are out of your system. We therefore require that you have someone else drive you home after ketamine sessions, and that you do not drive for the remainder of the day after ketamine administration.

 

In terms of psychological risk, ketamine has been shown to worsen certain psychotic symptoms in people who suffer from schizophrenia or other serious mental illness. It may also worsen underlying psychological problems in people with severe personality disorders. 

 

During the experience itself, some people have reported frightening and unusual experiences. These frightening experiences, however, may be of paramount value in your transition to recovery from the suffering that brought you to your KAP work. They will stop! You will receive psychotherapeutic support and ongoing guidance in the follow-up integration sessions which are an essential part of treatment. 


 

POTENTIAL FOR KETAMINE ABUSE AND PHYSICAL DEPENDENCE

 

Ketamine is a controlled substance and is subject to Schedule III rules under the Controlled Substance Act of 1970. Ketamine does not meet criteria for chemical dependence, since it does not cause tolerance and withdrawal symptoms. However, “cravings” have been reported by individuals with a history of heavy use of psychedelic drugs. In addition, ketamine can have effects on mood (feelings), cognition (thinking), and perception (imagery) that may make some people want to use it repeatedly. Therefore, ketamine should only be used under the direct supervision of licensed psychotherapists and physicians.

 

Repeated high dose and chronic use of ketamine has caused urinary tract symptoms and even permanent bladder dysfunction. This typically does not occur within the framework of our treatment.

ALTERNATIVE PROCEDURES AND POSSIBILITIES

 

No other medication or procedure is available in current, legal psychotherapeutic treatment which produces ketamine’s effects. Major depressive disorder (MDD), post-traumatic stress disorder (PTSD) and bipolar disorder are usually treated with antidepressant medications, tranquilizers, mood stabilizers and psychotherapy. Electroconvulsive therapy (ECT) and the recently introduced Transcranial Magnetic Stimulation (TMS) are also in use for treatment-resistant depression. Ketamine has also been used in the treatment of addictions and alcoholism as part of comprehensive and usually residential treatment programs, primarily outside of the United States.

 

CLIENT/PSYCHOTHERAPIST RELATIONSHIP

 

Research shows that a major factor in psychotherapeutic success is the relationship between clients and their psychotherapists. We pay close attention to the importance of building rapport and creating a space of trust and support where vulnerability is honored and healing is welcomed. Temenos’ KAP protocol often utilizes a co-psychotherapist or psychotherapist and physician team, generally of mixed-gender, thereby enhancing the psychotherapeutic bond and witnessing that is provided when two clinicians are in the session. Some sessions may be conducted by an individual psychotherapist, some with one of our psychotherapists and our physician, based on psychotherapist recommendations and client preferences. 

 

TOUCH, SAFETY, AND PROFESSIONAL BOUNDARIES 

 

KAP can be a very vulnerable process. We will do everything to assure your physical safety and comfort in the midst of working with some potentially uncomfortable psychological issues. Some clients find that the reassuring physical touch of a hand on the shoulder, hand or foot can be helpful to increase safety and connection. Others do not want any kind of touch at all. We will discuss the potential use of touch with you during your preparatory session, and assure you that touch will only happen when you request it and within the boundaries of appropriate professional contact. We adhere to strict professional boundaries, ethics and laws related to physical touch; and we state unequivocally that touch during ketamine sessions is never erotic, never to the sexual areas of the body, and never for the gratification of the psychotherapists or physicians. 

 

CONFIDENTIALITY

 

Legal and ethical codes require that information provided during psychotherapy be kept confidential at all times except under the following circumstances:

 

Sharing Information Amongst the Temenos Team: 

Temenos consists of a team of treatment professionals including licensed psychologists, a licensed clinical social worker and physicians. All client information is shared freely between team members as is deemed necessary for client safety and treatment efficacy by the team members.  

 

Release of Information: 

There may be circumstances in which it will be necessary or beneficial to release or exchange information about your treatment with other professionals such as your primary care physician or another psychotherapist or psychiatrist. In these situations, we will ask that you sign a HIPAA Release of Information form.

 

We may disclose limited information to necessary people without your permission if there is clear evidence that you are a serious danger to yourself or others.

We are mandated to breach confidentiality if we learn of an incident of child or elder abuse by you or any other identifiable person.

 

There are also some situations where the court can mandate that we release your records (i.e., you use mental health as a defense in a court proceeding). This is very rare; and should we receive a subpoena for your records, we will consult with you prior to responding.

 

Insurance Information: 

At your request, we will give specific information to your insurance company or another third party payer so that you may receive reimbursement. This information may include dates of service, diagnosis, and treatment summary. If your insurance company makes a request for more detailed information, we will consult with you before releasing such information to them.


 

PROFESSIONAL FEES

 

We provide KAP services within a standard package. This package is designed to be cost-saving as compared to the individual services. We require full payment for the package at the beginning of treatment. If you purchase a KAP package and later decide to terminate before using all of the services, you will be charged for the services you have received at the rates below and will receive a refund for the remainder of the money you have paid.

 

Fees for individual services:

 

Initial Psychological & Medical Assessment            90 minutes        $450

with a licensed psychotherapist and physician     

 

Integration sessions with two psychotherapists            50 minutes        $450?

 

Integration sessions with one psychotherapist            50 minutes        $225?

 

KAP Medicine session, psychotherapist + physician        up to 3 hours         $1150

 

KAP Medicine session, physician only                up to 3 hours        $750?

(Only available if you are in ongoing treatment 

and by agreement of the treatment team)

 

Final treatment recommendations, psychotherapist + MD        50 minutes        $375?

 

Standard 3-Session KAP Package  —  $4450

This is our standard KAP treatment package. 

 

This treatment package includes: 

  • One Initial Medical and Psychological Assessment Session with a physician and psychotherapist

  • Consultation with current or past treatment providers as needed

  • Three in-office KAP sessions

  • Two Integration sessions (with how many therapists?)

  • A final integration session with treatment recommendations for the future 

 

Insurance:  

We are happy to provide a statement so that you can seek reimbursement for these services from your insurance company. However, we are unable to offer any information about whether and how much your particular insurance company and plan may or may not reimburse for this treatment. 

 

Fee adjustments: 

We reserve the right to periodically adjust our fees, and will give you at least two weeks notice of any changes in our fees. Prepaid sessions and packages will not be subject to fee adjustments.

 

Telephone and email: 

From time to time, we may engage in phone contact and/or email exchanges with you for purposes other than scheduling. You are responsible for payment of the agreed upon fee (on a pro-rata basis) for these phone/email contacts which last longer than fifteen minutes. In addition, we may engage in phone contact with third parties at your request. You are responsible for payment of the agreed upon fee (on a pro-rata basis) for those phone calls that last longer than fifteen minutes. 

 

Payments are required at the time of your appointment, unless other arrangements have been made in advance. If at any point in the course of treatment you are unable to pay your bill, please discuss with us as soon as possible.

 

If your personal check is returned to us for insufficient funds you will be charged a $30 fee. Outstanding balances that remain unpaid for more than 15 days are subject to interest at a rate equal to 20% per annum of the outstanding balance. We have the option of using legal means to secure payment, including the use of collection agencies or small claims court. If such legal action is necessary, the costs of such proceedings will be included in the claim. In most cases the only information released about a client in such a process would be the client’s name, the nature of the services provided, and the amount due.


 

SCHEDULING AND CANCELLATION POLICY

 

Temenos requires one week’s notice to cancel a session without charge. If however — due to illness or another emergency — you cannot make your scheduled appointment and we are able to reschedule your appointment during the same week, you will be charged only for the session(s) that you attend. Please note that while we will make every effort to reschedule in emergency situations, it is often the case that there are no available times for rescheduling.

 

If you cancel an appointment within 24 hours of its scheduled time you will be charged the full fee for that session. If you cancel a session more than 24 hours but less than 7 days from the time of your scheduled appointment, and we cannot reschedule you, we will charge you one half of the normal fee for that session.


 

CONTACTING TEMENOS / EMERGENCIES

  

Although we are not available by phone 24/7, we welcome you to leave us a voicemail anytime at 707-992-5015. We check this voicemail on a daily basis, and make every effort to return your call within 24 hours during business days. We will inform you of exceptions for periods when we are unavailable.

 

If you have an emergency and cannot reach us, please call 911, Psych Emergency Services at 707-576-8181, or go to your nearest Emergency Room. 


 

ELECTRONIC COMMUNICATION

 

It is important to be aware that email, text and fax communications can be relatively easy to access by unauthorized people and that this can compromise your privacy and confidentiality. We do not have email encryption capabilities. If you choose to communicate confidential information to us via email, text, or fax, we assume that you have made an informed decision and view it as your agreement to take the risk that such communication could be intercepted. Please be aware that emails and text messages are part of the official medical record. Please do not use email or text messages to communicate emergencies.

 

I agree that Temenos may contact me via:

 

Cell phone     Y  / N             It is okay to leave a message    Y  / N  

Home phone    Y  / N        It is okay to leave a message    Y  / N  

Work phone     Y  / N        It is okay to leave a message    Y  / N  

Text - SMS     Y  / N         

Email         Y  / N


 

TERMINATION OF TREATMENT

 

You have the right to end treatment at any time without any legal or financial obligation other than those already accrued. If you wish, we will provide you with referrals to other qualified professionals. In some circumstances, people choose to stop psychotherapy when they are about to face something that is uncomfortable yet potentially very fruitful. For this reason, we request at least one session to discuss termination.

 

We also have the right to terminate treatment at our discretion. Reasons for termination include but are not limited to: untimely payment of fees; inability or unwillingness to follow treatment recommendations; or client needs which are outside the scope of our competence or practice. 

 


 

VOLUNTARY NATURE OF PARTICIPATION 

 

Your decision to undertake Ketamine Assisted Psychotherapy (KAP) is completely voluntary. Your signature to consent to treatment indicates that you have understood the benefits and risks of this treatment.

 

By signing below you are acknowledging that you have reviewed and fully understand the terms and conditions of this agreement and that you have discussed any questions. 

 

  • I agree to hold Temenos and individual clinicians free and harmless from any claims, demands or suits for damages from any injury or complications whatsoever, except for gross negligence or willful misconduct that may result from such treatment.

  • No oral or written statements, representations or inducements have been made to induce me into this treatment.

  • I fully understand that ketamine sessions can result in a profound change in mental state and may result in unusual psychological and physiological effects.





 

I give my consent to the use of the following medications if deemed necessary:  lorazepam for agitation, ondansetron for nausea or vomiting, and/or clonidine for blood pressure control during KAP sessions.

  • I have been given a signed copy of this Informed Consent form, which is mine to keep.

  • I understand the risks and benefits, and I freely give my consent to participate in KAP as outlined in this form, and under the conditions indicated in it.

  • I understand that I may withdraw from KAP at any time, including until the time of administration of the lozenge or intramuscular injection.

 

I voluntarily sign my name evidencing acceptance of the provisions of this agreement.



 

____________________________________________________________________________________

Signature of Client                                        Date

 

____________________________________________________________________________________ 

Printed Name of Client                    



 

____________________________________________________________________________________

Signature of Temenos Psychotherapist                            Date

 

____________________________________________________________________________________ 

Printed Name of Temenos Psychotherapist



 

____________________________________________________________________________________ 

Signature of Temenos Physician                                Date

 

____________________________________________________________________________________

Printed Name of Temenos Physician