“God, that was a trip…” My Client said as they slowly pulled back their blindfold.
“Were you able to explore any of that difficulty you have with forgiving her?” This was their first experience with ketamine, and I could tell that it had been pretty impactful.
“YEAH, there was so much. Like, I feel like I actually have an “inner-world” to share with her now…”
I mentioned part of this story in Part 1 of this blog. One of the ongoing conflicts in this couple’s negative cycle had been that this partner had felt their connection with their partner becoming more shallow, and they had even talked about feeling numb to their experiences. We had an integration session the following day where we made sense of some of the images that they had seen. This client was able to connect the pain they felt at their partner’s infidelity with the pain they felt being abandoned as a child. Their partner also had a positive experience in their medicine session and a few days later we came back together and had an integration session to help these partners share the new emotions and insights. They had been stuck on a plateau in their therapy, and talked the usual “just roommates” talk about the depth of their connection. When we came back together, one partner was saying that they could actually share about their emotions in a way where they felt seen. The other was saying that they felt they could actually take in their partners emotions more than they had since their conflict had started. They were both saying that felt they were seeing each other deeply for the first time in years…
Why Emotionally-Focused Therapy and Ketamine-Assisted Psychotherapy Together?
EFT is an integrative form of therapy that is built on Attachment Theory, Emotion Theory, Humanistic therapy, and Systemic approaches to therapy. It says that healthy relationships involve a secure attachment bond as a base, resulting in safe emotional connections between partners characterized by attunement and responsiveness to needs for care, soothing, intimacy, respect, and validation. The sticking point there for most couples is the relationship between safety and vulnerability. I can’t get vulnerable if I’m not safe with my partner. And the avoidant or anxious strategies that I use to help myself feel more safe in those situations often make me into a pretty unsafe partner myself. Which then makes my partner double down on whatever it was that was making me feel unsafe to begin with, and so on and what not. I think you can see why EFT Therapists often characterize negative cycles with the “infinity loop”.
Or that pretty much sums it up too…
People tend to often use either more avoidant strategies or anxious strategies, and this is why the way we cope tends to keep us stuck. The more avoidant partner goes inward and tries to feel less of the difficult emotion. The more anxious partner focuses outward and seeks relief from the other partner in their difficult emotions. Easy to see how that can turn into a viscous loop. So the basics of EFT are that we help the relationship deescalate the negative cycle, help the avoidant partner engage more emotionally, and help the anxious partner soften in their pursuing of relief from their partner.
So we have a therapy that is aiming to help people move through the protective responses related to amygdala activation in the brain and help them re-engage with and share their more authentic core emotional experience. In my work providing KAP for individuals, a big part of the benefit is helping people engage with vulnerable experiences that are often blocked by trauma triggers or rigid cognitive patterns of meaning making. Ketamine research has shown positive results in treatment-resistant depression for helping to alleviate rumination, suicidal ideation, and physical pain associated with depression. In Eating Disorder research, ketamine has been shown to alleviate the anxiety based symptoms associated with eating disorders. Ketamine has been shown to effect the Default Mode Network in the brain, which psychedelic researchers have proposed is related to the sense of “Ego Death”, the psychedelic common experience of having the Self dissolve, along with it’s rigid worldviews and beliefs. With all that it mind, KAP has just seemed like a wonderful way of helping couples do this work. Not to mention that after I saw that session video in part 1, I had a lot of confidence that KAP in combination with EFT could help couples move past the rigid places and engage in an intimate, authentic, and vulnerable way.
How Exactly Does Ketamine Assist This Therapy?
I have found the EFT process to work great for many couples. It’s a powerful thing to witness people get in touch with their vulnerability and share it in a way that they can receive the care and comfort they need, instead of react protectively in a way that drives their partner away. Helping people do that is a great passion of mine, and like I said, it works really well for so many relationships. I have also seen quite a few relationships where the process helps for a while and then it just doesn’t anymore. We start to loop back around to the same fights that they’ve had before even if we have made a lot of progress.
The couple I’ve mentioned in this blog were one of those. We had made it through Stage 1 of EFT which focuses on de-escalating the negative cycle. We had even started to move into Stage 2 which is when we start to get into the most core vulnerabilities for our clients and help them share their emotional experiences of their relationship and restructure their bond in a way that feels more safe and secure to them. One forgotten condom was all that it took though. The one partner found a condom in an old jacket of their partners. Long story short there was a brief conflict and the two of them figured out that this was from back when the one partner was having that affair and the condom seemed to have slipped into the lining of the jacket due to a cut in the fabric. The partner from the intro really did believe the other partner and there really was no question, it was just a forgotten relic. The partner who had the affair was dismissive at the beginning of the interaction though, and to the partner who had experienced the betrayal, they now felt that the impact of the affair had never been respected even though they had come so far. There was even a GENUINE attempt at repair with apologies being accepted and the whole nine yards! But contempt showed its face for the first time in their relationship.
Contempt is one of what the Gottmans refer to as the Four Horsemen of the Apocalypse for relationships, and of the four it is the single greatest predictor that a relationship will end. It is characterized by actions like eye-rolling, hostile humor, or personal attacks and feelings like disgust or disapproval. This is exactly what had shifted. The betrayed partner could no longer be as patient or attuned as they had been because they had this deep belief that their partner was allergic to accountability which led to them developing very negative beliefs about their partner’s character. In one approach to EFT, contempt is viewed as a constellation of anger, disgust, and critical judgements about someone’s worth. For this couple, therapy stalled because one of them stopped believing that the other was good. These individual medicine sessions had allowed both of these partners to have a deeper experience of themself and share it in a way that helped them truly feel seen. The betrayed partner was able to share parts of their hurt that they had never been able to acknowledge on their own. The partner who had the affair was able to validate them in that hurt and take responsibility for their actions in a more meaningful way than before. Warm-fuzzies were had by all! But if you’re anything like me by this point you’re wondering about the specifics of what this is good for?!
How and When to Integrate Ketamine into EFT
So let’s talk shop, my clinical friends! Psychedelics should be used with intention and purpose if they are going to be helpful in therapy. I do not believe that throwing a psychedelic medicine at people’s problems with minimal intervention will be very helpful for people in the long run. Psychotherapists have for years bashed a singular focus on psychotropic meds without engagement in therapy. Well I worry that we do the same thing if we work out of purely “sitter” based models of psychedelic healing. So how do these two things go together?
First, I want to be specific about what I am and am not saying. I am saying it is great for overcoming roadblocks in EFT. I am not saying that it will help if there has been NO progress or if the couple is getting worse in therapy (which is something that occurs). I am proposing this is a lubricant for the therapy process; I am not saying this is magic. EFT is not appropriate for couples experiencing active violence or abuse, couples where an affair is currently being maintained, or when a partner is struggling with active substance abuse/dependance. For these reasons, I think that we need to be solidly past Step 2 (Cycle Mapping) in order for medicine sessions to be a consideration. If we are encountering problems THAT early, it might be that the couple needs something other than EFT.
Second, I find it useful to start by clarifying why I am stuck in the EFT process. For me, the answer to this lies in what Stage and Step I am in. In the case of the couple I mentioned, the betrayed partner was stuck in Step 5, the experience of contempt was keeping him from taking ownership of their feelings of betrayal. The affair partner was stuck in Step 4, having difficulty taking ownership of the ways that their affair had impacted the development of their negative cycle. I also often see difficulty in Step 6 around moving toward acceptance of the other partner’s experience. I think that a medicine session at this point could help people if that acceptance were being blocked by a rigid sense of meaning-making around their partner's actions. I could potentially see medicine sessions being useful in Step 3 for those who may heavily dissociate during emotional experiences. The earlier on in the therapeutic process that medicine sessions occur, the more we should use our assessment of the therapeutic relationship to see if there is adequate safety for ketamine to assist the therapy process. If I am bringing up medicine sessions as a potential for a couple then I need to know what therapeutic task seems to be going undone. Otherwise, I think we run the risk of just throwing psychedelic meds at problems and hoping for the best.
Third, I do not believe that this will be helpful for mixed agenda relationships or any relationship where there is a question about commitment. I think that it is easy for us couple therapists to have a rosy view of relationships, but if we set out to EXPLORE something, that requires that we accept we do not know what we will find. If someone genuinely doesn’t know if they want to maintain their relationship, helping them attune to their core wants, desires, and needs could result in them finding that they no longer want their relationship. This risk is present anytime we try to help a relationship that is experiencing ambivalence, I just believe that potential outcome should be given the respect that it deserves when we are talking about a treatment that has a tendency to produce exaggerated outcomes. For that reason, I would only suggest this for relationships that have a clear goal in therapy and where partners are fully committed to each other and the process of growth.
Finally, we come to the question of individual or conjoint medicine sessions. As I talked about in part 1, I am choosing to not focus on conjoint psychedelic sessions as I believe that these are most helpful for relationships that are already mostly functional. That being said, conjoint psychedelic sessions could be useful in Stage 3 as couples move to consolidate and concretize their new, more positive cycle.
So for the majority of therapy, I am deciding between individual, psychedelic sessions and conjoint psycholytic sessions. This is a question about who the block belongs to. This roadblock might have been brought up by an interaction the couple had, but it was maintained by the individual, rigid thought process that would not allow one partner to view the other in a positive light. So we went for individual psychedelic sessions. In psycholytic conjoint sessions, my focus is to help couples interact from their vulnerability instead of their protectiveness. My aim is not to help them have a totally new experience so much as my aim is to deepen an experience that was too shallow.
I hope that is helpful, and maybe gives you a clearer picture of how this could be helpful for couples. And if nothing else, I hope it can just clarify some of what sounds like mumbo-jumbo when you hear us psychedelic folk talking about what we do…
