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Ketamine and psychotherapy. Do you need both?

Updated: Mar 8, 2023

Photo by Wonderlane

By the time ketamine treatments were suggested to me, I’d spent years in therapy. My first therapist caught me at the beginning of my unraveling. I’m sure he must have thought his kids’ college tuition was about to be paid for. It’s true. I was a goldmine.

Fast forward several more years and I’m struggling with suicidal ideations. For those of us with treatment-resistant depression (TRD), we try a lot of medications. They only work for a short time before our bodies metabolize them and bat the effectiveness away like flies at a park cook out.

Therapy alone doesn't always work

Gregory Hasler, in his 2019 study, noted that inflammation of the brain is one of the inhibitors to the effectiveness of cognitive behavioral therapy (CBT). In other words, no matter how much time and money we spend on a good therapist, our brains are fighting against us. We understand what to do, but we struggle to implement the plan.

Hasler says, "inflammation has specific effects on social cognition and behaviors, such as feelings of social disconnection, impaired social cognitive processing, and increased rejection sensitivity." The tropes of facing shame with exposure therapy, perceiving a relationship differently, or encouragement to find friends by talking to strangers, fall flat on the ears of a person who can't see past his own worthlessness.

I loved my therapist. I was appreciative of what we accomplished. But I was doling out cash like he was dancing on a stripper pole in stilettos, and I was a rapper with something to prove to my friends. At the end of the night I was still depressed, but a little less lonely.

Psychedelic treatments are different

Hasler says that "ketamine has the potential to enhance the effects of interpersonal and psychodynamic therapies [because of] its anti-inflammatory effects." One intramuscular shot or intravenous infusion of ketamine, for most, can turn that despairing frown upside down. Suicidal ideations are relieved and the effects of the treatment can last for days or weeks. Like taking an elevator out of the abyss, you suddenly find yourself standing on the sunny side of the street, licking the glaze off a donut, and sipping on a latte. The difference in mood can be dramatic.

Do you need psychotherapy anymore? It certainly doesn’t feel like it.

After several infusions, I found myself talking to a stranger on a plane. Abel, who once unwittingly picked up a prostitute he thought was a hitch hiker and befriended a guy who said he talked to demons, said she was too weird for him. I found her delightful. We were headed to Puerto Vallarta and she was getting off at the first layover. “Wouldn’t it be funny if you were actually an extrovert?” Abel asked.

Indeed, it would.

In Puerto Vallarta, our vacation didn’t go as planned. We each had ideas about what that week would look like and both of us were frustrated. Abel decided to go sit on the beach while I stayed in the room. Emotions swirled in my body. After several minutes, I realized that none of those emotions were feelings of self-pity or self-loathing. I didn’t default to thinking life would be better if I didn’t exist. Instead, I felt angry that I wasn’t getting my way and disappointed that things weren’t working out like I thought they would. After a long pause of contemplation, I furled my brow and said, “What the hell do I do with this?”

People with major depressive disorder (MDD) frequently have blunted emotions. This can be caused by childhood trauma, years of depression, or even the antidepressants themselves. A significant amount of the time we spend talking to our therapists is focused on trying to pull ourselves together. Sessions tend to be about functioning with depression, addressing negative self-images, thoughts of suicide, and skewed perceptions. But take away the depression and you find yourself staring squarely at pure, unfiltered – and healthy – emotions.

I sat on the bed and grabbed my phone. I decided to do an Internet search for what I was feeling. Since depressed people have a tendency to only see black and white, I felt I could either be angry or I could be disappointed. But I felt both at once. I later described this feeling to my doctor as “standing in shit.” I could see it. I could smell it. But I was perplexed by what to do with it. None of my pre-ketamine therapy prepared me for this.

Hello therapist, my old friend

For most, after psychedelic intervention, the depression that was the foundation for how they operated in the world is either gone or greatly diminished. Like moving from sixth grade straight into college, though, we’re not prepared for the lessons we’re about to learn.

When I went back to my therapist after vacation, I was thinking logically and reasonably. I’d taken notes during the week of things that had happened, how I felt, and what I wanted to discuss. Our sessions changed from maintenance to growth. The experience was like holding a glass ball of trauma in my hand. I could objectively look at it, analyze it, and see it for what it was without experiencing the pain.

Some providers offer ketamine treatments without requiring that the client receives therapy. One doctor told me he saw prescribing ketamine like prescribing anti-depressants. A patient is not required to go to therapy to take them. However, research shows that a combination of medication with psychotherapy “performed significantly better on patients than just therapy or just medication alone.

Ketamine may lift you out of your funk, but the chances of lasting change will likely require the help of an insightful therapist who can walk you out of the shit.

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