Ketamine-Assisted Couple Therapy Part 1: How Would That Even Work?!

On a warm summer afternoon, a client of mine sat down in the big comfy chair in my office. Their blindfold rested on their forehead, and they stared at the ketamine sitting in a saucer as I finished taking their vitals to see if they were in a safe range. The client noticed that their blood pressure was slightly higher, although still in range. 

“I guess I’m nervous.” He quipped with a slight grin.

“Do you want to tell me about that?” I asked, starting to wonder if this client was having second thoughts. 

“She just means too much, I can’t keep this up forever…”

“Sounds like your intention for today shifted a little since we talked last?” There was a deeper sadness in his voice than I had heard in our last few sessions. 

“I need to know what I’m holding onto. I need to know why I can’t let go of the past, even though she loves me. I want to explore that.”

I would not have considered Ketamine-Assisted Psychotherapy (KAP) for couples when I first started. It really seemed counter-intuitive. Here we are dealing with a dissociative anesthetic and the model of couple therapy that I use is all about having an embodied experience of emotion. The medicine puts people a bit outside of themself instead of having an embodied sense. On top of that, the people who talked about psychedelic couples therapy back then also just talked about it in a way that I couldn’t really believe. I had been focused on couple therapy for several years at that point. Not only could I not see any of my couples back then experiencing such a drastic change so quickly, I couldn’t imagine them being safe enough for each other for medicine sessions to even be possible. I just couldn’t picture it and it felt like all hype. Like some part of me wasn’t sure how an experience that would go away after the acute effects of the medicine. And still there was this lingering wish, because focusing on couple work had put me and parts of my world view through the ringer. 

At that stage, couple therapy was a rough experience for a lot of reasons. We’ll get to the “why?” question when it comes to KAP and couples in part 2 of this blog. Because in the beginning, I didn’t even consider this for couples because I couldn’t even picture HOW it would work? What would this even look like in therapy. How could a couple even get anything from this process? What the hell even is that process?! 

How Would That Even Work?!

Pictured: My totally normal internal thought process…

I was very skeptical initially, a bit confused, and probably more intense about “figuring it out” than I needed to be . I first heard of this in the context of ketamine-assisted therapy retreats for couples. The description that I got was that couples would come together at these group retreats. The group facilitators create the context and container for the experience. This involved agreements that seemed very similar to regular group therapy. We respect people's experience when they are sharing and we don’t interrupt, we prioritize each other’s confidentiality, all that jazz. The main difference was that during the time of the psychedelic experience people are doing things very similar to the individual KAP medicine sessions. They put on a blindfold and weighted blanket and have an internal experience before coming back together as a couple. 

From there it sounds like it goes two different ways. One method has the couples take their dose at the same time. They had their psychedelic experiences and then they would process their experiences together once the psychedelic effects had ended they were in a more psycholytic state. Another would have one hold the space for the other while they are dosed. Then as the one comes out of the experience, the other is dosed and they trade spaces with the other partner now holding the space. These models are variations of the model that was proposed by Phil Wolfson, a top researcher in the therapeutic uses of ketamine. 

All of that sounds really nice, and it all also sounded too good to be true. As a matter of fact, I had to stop myself from laughing at my friend when they described this protocol to me. What she didn’t realize was that I had just come out of a session in which one partner revealed to the other that they had been maintaining an affair for the past year. This sudden deepening of connection that these couples experienced sounded like fairy tales to me. Couples therapy had me burned out by that point. I had just stared into the sun for a bit too long. I had been watching partners hide affairs from “the love of their life.” I’d watched couples where one partner just refused to change their substance use patterns even though it was obviously hurting their partner. I watched partners refuse to shift in their stance after hearing their partner’s deepest fears underlying their fights. Sure, I had also helped quite a few couples. It’s just that if you stare into the sun long enough, you stop seeing the light. And I could not fathom ANY world in which a partner would just “hold safe space” for their partner without getting reactive. To put it bluntly, I thought any therapist that believed couples would behave in that way had their head up their ass. 

That was my opinion for a while. I’d deflect the question anytime someone would ask if I had plans to integrate my two specialties. I did this weird dance where I didn’t want to let people know that I didn’t experience couples therapy as having much depth anymore, and I didn’t really even see couples changing how they treated each other that much, even when it did help. But I started to realize that I hadn’t quite picked up on something before. When I heard my friend and others talk about these models they all used this same word: deepening. I don’t know how I missed it before, but I was getting hung up on an implication that no one seemed to be slowing down and saying out loud…if this was deepening their connection, the implication is that the couple was connected to begin with. 

The majority of the couples that I had worked with at that stage had their connection interrupted or severed and some had never been as close in their connection as they thought. I realized why it sounded so unimaginable, their clients were not my clients! This model was helping couples deepen their connection, it wasn’t proposing that this was the go-to when clients are in crisis. My couples fought and stayed in negative cycles on a regular basis. I was incorrect for thinking that anyone was proposing that my clients would benefit from taking ketamine in a therapeutic context together. So I loosened up a little. I thought that KAP for couples is a nice idea for some, but just not for me and my clients. But then I started hearing about other models for ketamine-assisted couples therapy. 

WHAT DID I JUST SEE?!

I went to a conference and got to hear about a lot of emerging research pertaining to psychedelic therapy with couples. One of the reasons that I had just written off KAP for couples was because I didn’t really hear about people doing this work with specific models of therapy. I understood the protocol well enough, but I couldn’t actually picture what I would be doing as the therapist in that context. When I was at Psychedelic Science ‘23 that started to shift. I sat through multiple presentations on MDMA with couples using Cognitive Behavioral Conjoint Therapy, which had shown to be helpful in couples where someone had struggled with PTSD.

I am no CBCT therapist, but I could at least picture what people were talking about now. Then I got to hear about some upcoming research projects aiming to use KAP in helping couples through the VA. These studies are aiming to integrate KAP with CBCT in order to help veterans dealing with PTSD. I was slowly starting to warm up to the idea. Especially since I was also starting to hear people emphasizing a psycholytic approach to dosing as well. Psycholytic dosing is simply a low dose which does not induce a psychedelic experience, but people are able to communicate clearly and maintaining their physical awareness. When people talk about using this in therapy, it is often referred to as a “heart-opening” dose for helping people bypass secondary, protective responses and engage with their more vulnerable experiences. 

And all of that had a bow put on it when I got to watch a session with Dick Schwartz, the originator of Internal Family Systems therapy (IFS). The quick version of it is that our psyche is made up of “parts” of ourselves that we are in communication with. Our problems arise when we are acting from these difficult, wounded, or underdeveloped parts instead of acting from our healthy “Core Self”. It’s not a form of therapy that I do, but definitely a way of working that I really believe in.

So in this session, I watched Schwartz doing IFS with a couple who had been given a psycholytic dose of ketamine, and I couldn’t believe what I was watching. I saw him help this client go through identifying a previously unknown Exiled Part, they went all the way through the unburdening process, and they processed the shifting experience with their partner and were able to reconnect! A couple minutes in, I realized I was watching something interesting so I hit my stopwatch…all of this happened in the span of 12 minutes!!! That might not mean much if you don’t know IFS, but for context even just the process of making ourselves aware of our unknown/avoided experiences often takes multiple sessions. And I just saw it happen in minutes!

Pictured: Me in a professional context, enjoying a clinical presentation…

The aftermath of an “Aha” moment…

Now I could actually picture it! It wasn’t just a way for mostly stable couples to deepen their connection, forms of psychedelic therapy can be helpful for distressed couples too. It will just look different. Some of what those therapists were saying made a lot of sense to me too, even though I have no training specifically in CBCT or IFS. There was a through line too. All of those researchers and therapists kept using the same word that I have heard so many couples use to describe themselves…”stuck”. Sometimes, our models of therapy just stop working, we stop making progress, or something is blocking therapy from doing what it’s supposed to. 

Sometimes that block to therapy is a client’s resistance. Which brings us to the part where I started to ask how I would do this. Even though I don’t know CBCT or IFS I know blocks to therapy, especially in couples therapy. Couples will block you from helping them at almost every turn. Because if we are honest with ourselves, there is a lot of reasons to stay rigid with our romantic partners. Most of those reasons boil down to it just being safer. 

Which is why I brought up that client from the beginning of the blog. I had been working with this couple for quite a while. We had reached a place in therapy where it felt like we were spinning our wheels. A lot of things had shifted for the better except for one thing, this client could not forgive their partner for an affair that she had years before they ever came to see me. It was so far in the past, and he could even empathize with the shame that his partner felt for the affair. He believed at a meaningful level that she was deeply remorseful, and still could be triggered into rage and distrust. It had become a block to therapy moving any further because the walls would go up every time we approached it. 

I knew now that KAP would be helpful during the parts of couple therapy where we get blocked or the process gets gummed up for some reason. The other message I had taken from things I learned was that there was value to both the psycholytic and psychedelic experiences in couples therapy, but now I needed to be able to determine which would be more helpful. We’ll talk more about resistance in Part 2 of this blog, but the important part for now is that I was able to work out an assessment question, “Is this resistance/block/stuck place maintained by their interactional pattern or is it maintained by one person’s internal processes?”

I decided that individual psychedelic sessions would be the best approach because the resistance to “letting go” was a problem that the client experienced fully as within himself. It was really only a problem between the two of them other than when he might act out of that rage. Now I could also picture a scenario where the other partner would only be remorseful that they got caught or might be continually dismissive of the impact their actions had. If that had been the case, we would have gone for psycholytic conjoint sessions. 

Vulnerability in some form is often what is underneath our resistance. It is so hard to allow ourselves to be soft and vulnerable. It’s meaningful because it isn’t always safe to open up in that way. It makes all the sense in the world that we build blocks and walls to our vulnerability. So the real question is how am I helping this couple be more open and vulnerable. Am I helping them be more vulnerable with each other because there’s a wall between them, or am I trying to help someone attune to their own vulnerability which they might have exiled out of their own awareness? 

There’s different approaches for different couples, but I had started to figure out that I had really been so skeptical because psychedelics get sensationalized these days, and people can make very broad claims. But I learned that KAP can be helpful for couples as they are running into blocks, not just those trying to have a deeper connection in their already good relationships. And if you come back next week, I’ll be sharing some about how I assess resistance and integrate Emotionally-Focused Therapy with KAP to help those couples who just keep feeling stuck…

Warmly,

Ryan