Ketamine-Assisted Couple Therapy

Ketamine-Assisted Couple Therapy 

A couple recently shared this with me during an assessment session for ketamine-assisted couple therapy:

“We’ve been stuck in the same place for years. We love each other, but we don’t know how to move past the hurt. There has been too much pain and we’ve built our walls too high. We don’t understand each other and any attempts to tell our perspectives result in conflict or more distance.”

Ketamine is a legal psychedelic in the United States and is emerging as a promising therapeutic medicine. It has been used to effectively treat a range of mental health challenges, including anxiety, depression, bipolar disorder, and suicidal ideation (Walsh et al., 2022). Ketamine’s precise mechanisms are still being explored, but theories suggest it increases neuroplasticity, dopamine, and serotonin, and alters brain connectivity (Aleksandrova & Phillips, 2021) to promote more flexible thinking, greater perspective taking, empathy, openness to experience, and reduced avoidance. These cognitive, emotional, and behavioral shifts are important for moving through relationship pain, creating new patterns, and building healthy connections. Indeed, across different couple therapy approaches, the primary goals typically include identifying harmful patterns, increasing understanding and empathy, and improving communication in order to build closer and more fulfilling intimate connections. 

So how do we use ketamine therapy to help couples heal? 

We begin with one couples’ assessment session and one individual assessment session for each partner, where we discuss your goals for treatment, where you have been feeling stuck, and your individual history and sensitivities that influence relationship interactions. For example, if your parent or caretaker interacted with you in a way that made you feel undesirable and worthless, you may be particularly sensitive to feeling rejected. This is something that it is helpful to be aware of in order to notice and shift those cognitive distortions for you. It can also be helpful for your partner to be aware of so they can engage in efforts to let you know they do desire you and remind you of your worth, as you are rebuilding this confidence. One very important piece of the assessment phase is to outline the primary dysfunctional behavioral pattern that you and your partner get stuck in. For example, one couple described their pattern this way:

“When there is a conflict, he shuts down and walks out of the room and I follow him and try to explain my perspective so that he will understand and change his behavior. He interprets this and criticism and avoids me further. I feel more sad, alone, and abandoned so I criticize him because I’m hurt. He feels shame and has the thought that he is bad and can never get it right. We both feel tension and sickness in our stomachs, but we don’t know how to do it differently.”

The content of arguments is less important than the pattern that ensues over and over again. Once we can identify and interrupt this pattern, that will translate across the majority of interactions, regardless of what the specific conflict is about. 

After this initial assessment, we collaborate with clients to develop a treatment plan and discuss how ketamine will assist with shifting our identified treatment targets. Because ketamine is a dissociative medicine, it can move us into an observer perspective where we can view this pattern from a more removed, third-person point of view. So rather than you against your partner, it will be you and your partner working together to shift the pattern, with the help of your therapist. Ketamine assists with creating cognitive flexibility so that the stories in our mind feel less rigid and we can start to incorporate curiosity about our partner and about new ways of thinking. Ketamine also promotes openness and empathy and reduces avoidance. One very common experience of ketamine is a feeling of oneness and letting go of attachment to resentment and a painful past. 

From this treatment plan, we move into preparation for the first ketamine medicine session. This is an opportunity to discuss expectations, intentions, and any fears or ambivalence about the medicine session. We take the perspective that all experiences during medicine sessions are welcome - all feelings are acceptable and temporary,  and there are no “bad trips” when it comes to therapeutic ketamine sessions. People may have challenging experiences at times, but even very challenging medicine experiences can be healing, especially with the support of an experienced therapist. 

As a ketamine-assisted couple therapist, I create a safe and comfortable environment for the medicine session, which will last about 3 hours in total. This experience is typically  internally-focused, with patients wearing eye masks and guided by evocative, instrumental music. You and your partner will be beside one another in reclining chairs. During the medicine session, you will be following your internal journey that is guided by the intentions you set before the session, including whatever you want to explore about healing your relationship. You and your partner may want to hold hands or have soft interactions during your journeys, or you may simply quietly share the space together. Toward the end of your medicine session as the peak experience subsides, we will begin some gentle integration with deeper integration during follow-up sessions. 

 If we think of a medicine session as the process of shaking up a box of puzzle pieces (like stuck patterns, thoughts, and emotions), then integration is the process of beginning to put the puzzle together. First, we put all the puzzle pieces out on the table, reflecting on our medicine session experiences and sharing them with one another. Then we start to flip the pieces over and see how they fit together, what meaning we want to make of them, and how they fit into the larger structure of your life. In couple therapy, this usually means looking at any shifts in how you are thinking and feeling about your relationship and your partner, as well as changes in how you see yourself and how you want to show up in your relationship. It may take multiple integration sessions to identify, vulnerably share, and shift relational patterns.

Sometimes couples engage in just one medicine session, but often we will use between 2 and 8 medicine sessions to help support your treatment goals. Each medicine session is followed by at least one integration session, and I typically guide couples through medicine sessions once every few weeks or months as we continue doing deep relational work in between. We can continue this work until couples feel good about achieving the goals they identified during the assessment.

Through ketamine-assisted couple therapy, many couples heal their relationships and move forward together with high levels of satisfaction and love, even if they’ve been stuck and struggling for years or have tried couple therapy before without much success. No treatment works for everyone all the time, and some couples will choose to end their relationships as a result of this treatment. We still need to do a lot more research to find out who can get the most benefit from ketamine-assisted couple therapy and how we can make it more effective and accessible for anyone who needs it. In my clinical experience, I have seen couples make profound shifts in their relationship and have seen deep relational wounds heal, and I am extremely hopeful about the potential of this powerful treatment to help couples create the relationships they want and need.