Updated November 2026 · By Joel Blackstock, LICSW-S

No. Ketamine therapy is still legal in Alabama. What changed is who may provide it and how. In April 2024 the counseling board warned that counselors using ketamine without a physician present risk charges of practicing medicine without a license, and in August 2025 the Board of Medical Examiners issued guidelines, revised in January 2026, requiring physician prescribing, on-site monitoring and no at-home psychiatric use.^{1, 2}

For someone with PTSD, the more important question is not legality but fit. Ketamine’s most reliable acute effect is dissociation, a temporary loosening of the connection between a person and their body, surroundings and sense of self. For trauma survivors whose symptoms are already dissociative, that pushes in the wrong direction, and the research behind ketamine for PTSD has barely looked at them. That is the argument of this article.

I appreciate IV ketamine for depression, and I have seen it help some people with acute PTSD symptoms such as panic and traumatic re-experiencing, where fast relief matters. Where I don’t recommend it is for dissociative patients, because giving a dissociative drug to someone who already dissociates often produces experiences that are frightening rather than therapeutic. Trauma and PTSD are slippery conditions that need careful treatment, and often it simply takes getting to know the person to find what they respond to, whether that is brainspotting, EMDR, Internal Family Systems or another approach.

What Alabama actually changed

Two state boards acted. Neither banned ketamine.

On April 30, 2024, the Alabama Board of Examiners in Counseling posted a short statement on ketamine-assisted therapy. It said that situations where ketamine “is advised or used by a counselor in a counseling setting without a physician present” fall under the jurisdiction of the Alabama Board of Medical Examiners, that complaints about counselors would be forwarded to that board, and that civil or criminal charges for the unauthorized practice of medicine could follow.¹ Under Alabama law, practicing medicine without a license is a Class C felony.³

In August 2025 the Board of Medical Examiners issued a position statement and guidelines on the off-label use of racemic ketamine for treatment-resistant depression in outpatient settings, and it revised them on January 15, 2026.² The board’s position is that off-label ketamine for depression is the practice of medicine. The requirements are concrete:

• Only a physician licensed in Alabama and trained in ketamine may prescribe it. If that physician is not a psychiatrist, the depression diagnosis must be confirmed first; the 2026 revision lets the patient’s treating psychiatrist or primary care physician confirm it.
• Ketamine is not a first-line treatment. It is considered only after adequate trials of at least two antidepressants from two different classes.
• It should not be given to anyone with a current diagnosis or history of schizophrenia or schizoaffective disorder, current uncontrolled hypertension, a current pregnancy, past or current ketamine use disorder, or a previous serious reaction to ketamine. Physicians must use extreme caution with any past or active substance use disorder.
• Screening includes written informed consent, a full history and physical examination, and a urine drug screen.
• The prescribing physician stays on site, and the physician and any licensed staff who assist must be ACLS-certified. Oxygen saturation, blood pressure and heart rate are checked every five to fifteen minutes, staff watch for “signs of dissociation or distress,” and the patient is monitored for at least two hours and then driven home by a caregiver.
• Infusions are given no more than twice a week, and the physician should stop if there is no improvement after four to six infusions.
• A physician should never allow a patient to take ketamine at home for psychiatric reasons.

Two details matter for PTSD. First, the guidelines are written for depression. Patients must have a current diagnosis of major depressive disorder, and the position statement notes that ketamine is not FDA-approved for PTSD.² The board did not create a separate pathway for PTSD on its own. Many people with PTSD also meet criteria for major depression, and for them depression is the indication the guidelines address. Second, the ban on home use runs directly against the take-at-home model that spread nationally after pandemic-era telemedicine rules made off-label, unsupervised use easier.⁴

For therapists, as I read the two statements, the line looks like this: integration therapy with a sober patient who received ketamine from a separate medical practice is psychotherapy, while being present for, coaching or monitoring the drug session itself belongs inside a physician-run practice with the physician on site. That is a clinician’s reading, not legal advice, and I cover it in more detail in our Alabama legal update on ketamine-assisted therapy.

Why the scrutiny: Matthew Perry and the off-label market

Matthew Perry died on October 28, 2023, at 54. The Los Angeles County medical examiner ruled the death an accident caused by the “acute effects of ketamine,” with drowning, coronary artery disease and the effects of buprenorphine as contributing factors.⁵ Perry had been receiving ketamine infusions for depression and anxiety, but his last one was about a week and a half before he died, and the examiner concluded that the ketamine in his blood could not have come from it. The level in his peripheral blood was 3,540 nanograms per milliliter, within the range usually seen during monitored surgical anesthesia.⁶

Federal prosecutors charged five people in August 2024, including two physicians, Perry’s live-in assistant and a dealer known as the “Ketamine Queen.”⁷ Perry had been taking ketamine legally for depression but wanted more than his doctor would give him. According to the assistant’s plea agreement, the assistant bought it off the books from another doctor, and in Perry’s final days the assistant was injecting him six to eight times a day. All five were sentenced by May 2026; the dealer received 15 years in prison.⁸

The lesson cuts two ways. Perry’s death was not what happens in a monitored clinical protocol. It was what happens when a person with a long addiction history, money and access goes around the doctor who is telling him no. Saying that his death proves ketamine therapy is dangerous is like saying acetaminophen should be banned because a whole bottle can kill you. At the same time, the case showed how loosely the off-label market was supervised, including by licensed physicians willing to sell the drug outside any treatment plan.⁷ Yale psychiatrist Gerard Sanacora made the clinical point in 2023: “It is critical for it to be a part of a comprehensive mental health plan, not in isolation.”⁴

The contrast with esketamine is useful. Spravato, the nasal spray the FDA approved in 2019, can be given only in certified settings under a federal risk program, with at least two hours of monitoring, and its label carries a boxed warning that includes dissociation.⁹ Racemic ketamine, the generic anesthetic used in infusion clinics, is not FDA-approved for any psychiatric condition, and its psychiatric use has no comparable federal program. Alabama’s medical board gave its own reason for acting: national trends in off-label use had produced situations in which non-physicians were prescribing and administering ketamine for depression.²

What the evidence shows for depression and for PTSD

For treatment-resistant depression the evidence is real. In a two-site randomized trial of 73 patients, 64% responded within 24 hours of a single ketamine infusion, compared with 28% of those given midazolam, an anesthetic used as an active placebo so that participants could not easily tell which drug they received.¹⁰ In an Ottawa trial, 59% of participants responded after a two-week, open-label course of six infusions.¹¹ A 2022 meta-analysis of real-world data, pooling 79 studies and 2,665 patients, found about 45% response and 30% remission, with wide variation between patients.¹²

For suicidal thinking, a Columbia University trial of 80 depressed adults found that 55% of those given ketamine had at least halved their suicidal ideation scores a day later, against 30% on midazolam.¹³ That is a fast drop in suicidal thinking, not proof that ketamine prevents suicide. Anyone in that situation right now should use Birmingham-area crisis resources or call or text 988.

For PTSD the picture is thinner and less consistent. Adriana Feder’s group at Mount Sinai found that a single infusion reduced PTSD symptoms at 24 hours more than midazolam in 41 patients,¹⁴ and in a 2021 trial of 30 patients, six infusions over two weeks produced a 67% response rate against 20% for midazolam, with responders keeping their gains for a median of 27.5 days.¹⁵ The largest randomized trial of intravenous ketamine for PTSD points the other way. In 158 veterans and service members given eight infusions over four weeks, neither dose tested improved PTSD symptoms more than placebo, although the standard dose did improve depression.¹⁶ That one trial enrolled about half of all participants in the seven intravenous trials included in a 2026 systematic review, which found clear improvement over control in only two of them, though its authors still concluded that intravenous ketamine may be effective and deserves further study.¹⁷ A 2024 meta-analysis of the randomized trials found only a small advantage for ketamine, which shrank and lost significance after correcting for small-study bias. Two weeks after the first infusion there was no significant difference from control conditions, and the authors argued that broken blinding, with participants able to tell they had received ketamine, may account for much of the apparent effect.¹⁸

Guidelines follow that evidence. The 2023 VA/DoD guideline for PTSD suggests against ketamine for treating PTSD, a weak recommendation based on very low-quality evidence, while the 2022 VA/DoD depression guideline suggests ketamine or esketamine as an augmentation option once several medication trials have failed.¹⁹ For PTSD itself, the VA/DoD recommends trauma-focused psychotherapy, specifically prolonged exposure, cognitive processing therapy or EMDR, over medication.²⁰

Why dissociative patients are a different case

Ketamine was first given to a human in 1964, and the FDA approved it as an anesthetic, sold as Ketalar, in 1970. The term “dissociative anesthesia,” coined by the wife of pharmacologist Edward Domino, described patients who looked awake but did not respond to the world around them.²¹ At the lower doses used in psychiatry the effect is milder but still the drug’s most dependable one. In a 1994 placebo-controlled study of healthy volunteers, a 40-minute subanesthetic infusion produced perceptual changes and symptoms resembling dissociative states.²²

One leading explanation, among several that are not mutually exclusive, is that ketamine blocks NMDA glutamate receptors, with an outsized effect on the inhibitory interneurons that normally restrain cortical activity. The result is a brief surge of glutamate signaling and, downstream, growth of new synaptic connections, one proposed basis for its antidepressant effect.²³ In 2020, Karl Deisseroth’s lab at Stanford showed in mice that ketamine induces a slow 1 to 3 Hz rhythm in deep layers of the retrosplenial cortex, and that driving that rhythm artificially reproduced dissociation-like behavior. In one patient with epilepsy, recordings from electrodes in the corresponding human brain region showed a similar rhythm that tracked the dissociation the patient reported just before seizures.²⁴

Is the dissociation the medicine? Probably not. A 2020 perspective by Elizabeth Ballard and Carlos Zarate of the National Institute of Mental Health concluded that the literature does not support the idea that dissociation is necessary for ketamine’s antidepressant response.²⁵ For most patients that is reassuring, because the trip is a side effect rather than the treatment. For a dissociative patient it means the dissociation is a cost with no evidence that it is doing therapeutic work.

Dissociation in PTSD is not rare. Ruth Lanius and colleagues described a dissociative subtype of PTSD marked by emotional overmodulation, meaning depersonalization, derealization and numbing rather than the more familiar hyperarousal,²⁶ and DSM-5 added a “with dissociative symptoms” specifier for PTSD in 2013.²⁷ A 2025 meta-analysis of 123 articles that used one standard measure, the Clinician-Administered Dissociative States Scale, found the highest baseline levels in the dissociative and complex subtypes of PTSD. Ketamine produced state dissociation comparable to, and in the point estimates somewhat above, those baseline levels, with larger effects in healthy volunteers than in patient samples, and the authors flagged the implications for measuring adverse events in drug treatments.²⁸ Put plainly, at research doses ketamine can briefly produce dissociation on the scale that the most dissociative PTSD patients report as their starting point.

The trials say little about what happens next for those patients. They report ketamine’s dissociation as short-lived: in the veterans trial it returned to baseline within two hours and lessened with repeated doses,¹⁶ and the first Mount Sinai trial found no clinically significant persistent dissociative symptoms.¹⁴ Those are averages across mixed samples. I could not find a controlled trial that tested ketamine specifically in the dissociative subtype of PTSD or in people with dissociative disorders, and a systematic review in The Lancet Psychiatry found selective side-effect reporting in ketamine depression research, with little assessment of long-term or repeated use.²⁹

That gap is where clinical observation has to carry more weight than usual, with the caveat that an observation is a hypothesis, not proof. What I see at Taproot Therapy Collective is that the patients who come to us worse after ketamine, in crisis and saying they can no longer contain what it set off, have in my experience almost always been dissociative. We are careful about giving stimulants to people with panic, and we should be at least as careful about giving dissociative drugs to people who dissociate. Clinicians often ask me what research supports this. The honest answer is: not much yet. But it seems self-evident that something which increases the symptom a patient is trying to reduce is probably not a good drug for that symptom. We have to be empirical, but empiricism begins in the therapy room.

Dissociation is a bit like riding a bike: once the brain knows how to do it, it keeps that ability. Many patients with dissociative disorders tell me the first time they dissociated was during a drug trip gone wrong, and the symptom persisted afterward. That fits research on depersonalization disorder. In an internet survey of 394 adults with chronic depersonalization or derealization, about half said their symptoms began with illicit drug use, most often cannabis or hallucinogens, and their illness looked the same as in people whose symptoms started some other way, although the drug-triggered group reported more improvement over time.³⁰ Ketamine was not among the most common triggers in that sample, and a survey cannot show cause. It is consistent with the clinical worry that, for some people, a strong dissociative experience can open a door that does not easily close.

Ketamine without therapy

The second problem is how ketamine is often delivered. In many clinics, and in some research protocols, the drug is given under fluorescent lights to a person alone in a room with music or a phone, and nothing designed to help them make sense of what comes up. Some of my patients with complex trauma, people who had white-knuckled their way through life and never had a safe environment even in childhood, took part in ketamine studies at large hospitals. What they described was infusions without preparation or integration, more infusions after they reported getting worse, and then removal from the study without a plan for what came next. When a drug brings traumatic memories and somatic states to the surface, it stands to reason that the person needs support to understand the parts of self that are emerging. It is strange to me that this is not built into more of the research.

The evidence on combining the two is early. A 2026 individual-participant meta-analysis of 12 studies pairing ketamine with psychotherapy for PTSD found that more psychotherapy sessions, and more ketamine sessions, were associated with greater improvement, although nine of the twelve studies were rated poor quality and only baseline severity held up in the higher-quality subset.³¹ Alabama’s guidelines make the same point in one sentence: “Treatment by psychotherapy should be considered in tandem with ketamine administration.”²

What this looks like in therapy

When someone asks me whether to try ketamine for PTSD, the conversation starts with dissociation, not with the drug.

Screen for dissociation first. That means asking about lost time, feeling unreal or outside the body, emotional numbing, abrupt shifts between very different states, and what happens under stress. Many people do not know that what they live with has a name, and this overview of dissociation is a reasonable place to start. Anyone with prominent depersonalization, derealization or a dissociative disorder should raise that history explicitly with a prescriber before any infusion.

Stabilize before intensifying. Judith Herman’s model in Trauma and Recovery puts establishing safety first, then remembrance and mourning, then reconnection with ordinary life.³² That order still holds for complex trauma as Herman described it. An infusion can drop someone into material they have no way yet to hold. Phase-oriented therapy builds that capacity first, including learning to recognize the slippery emotional slope that leads into a dissociative episode and practicing ways back.

Work with altered states in a form that can be paused. In-session methods that narrow attention, such as brainspotting, or that use trance, such as clinical hypnosis in the Ericksonian tradition, can be slowed or stopped from one minute to the next, which is much harder once a drug has been given. They are not risk-free for dissociative patients either, and the pace has to be titrated; we have written about how we brainspot patients with severe dissociation. Brainspotting’s research base is still small, a tension taken up in a piece on why academic psychology has been slow to study it.

If ketamine is the right call, pair it with therapy. That usually means severe depression that has not responded to other treatment. The therapist’s role is integration with a sober patient, coordinated with but separate from the medical practice: making meaning of what surfaced, tracking whether dissociation is rising or settling between infusions, and telling the prescriber when it is getting worse. Whether to start, continue or stop is a decision for the prescribing physician.

If ketamine has already made things worse, slow down. People in that position usually need containment before exploration: grounding, orientation, sleep and a slower pace, before returning to the trauma itself.

Questions to ask an Alabama ketamine provider

• Is the prescriber an Alabama-licensed physician, and will they be on site during the infusion?
• Who confirmed the depression diagnosis, and has anyone asked me about dissociation?
• How will I be monitored during the infusion, and for how long afterward?
• What happens if I feel worse, during the session or in the days after?
• Is therapy part of the plan, and who provides it?
• Is any part of this treatment supposed to happen at home? Under the board’s guidelines, it should not.

If dissociation is part of your history and you are weighing ketamine, or trying to recover from a ketamine experience that went badly, it helps to talk it through with someone who works with dissociation directly. Our dissociation therapy in Hoover is one option, and you can contact Taproot with questions. Medication decisions stay with your physician; our part is the therapy.

References

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