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Controlled Ascent: How Therapy Can Help You Avoid the Therapeutic Bends From Ketamine Assisted Psychotherapy

  • Traditional definition of The Bends: Undesirable effects that happen to scuba divers when they ascend too quickly from the depths.
  • Definition of The Therapeutic Bends: Dysregulation that comes with the rapid recovery (via ketamine) from negative mental health symptoms.

In 2018, Jessica Katzman PsyD wrote about a phenomenon which has become known as the therapeutic bends. In her article titled, “Rapid Depression Remission and the ‘Therapeutic Bends’ with Ketamine-Assisted Psychotherapy,” she describes six areas whereby patients undergoing ketamine-assisted psychotherapy or KAP may encounter setbacks. But instead of delaying progress, Dr Katzman suggests that these challenges result from feeling better too quickly like a diver who makes an uncontrolled ascent from the deep sea.

Why managing change is vital

Imagine somebody blind at birth. Then, decades later their sight is restored. We think of the wonder and joy they may feel. But what we fail to grasp is not only will they see the beauty, but also the not-so-beautiful. The forest is beautiful after the spring rains. It is less so after the forest fire. Seeing comes with a price. [Editor’s note: Of course, the benefits of vision make sight a worthy object for most.]

I feel better. Now what?

How does one act when mental health symptoms such as depression and anxiety are no longer present. And now who am I? What about all of the people: friends, family, colleagues, mentors, and familiar faces who occupy the patient’s orbit? Often overlooked is the fact that roles and relationships must also change. This can be just as dysregulating as it is for the patient, resulting in the proverbial ripple effect. If you’ve ever watched When a Man Loves a Woman you know what that shift is like.

Often, we lament (in a good way, mostly) about traditional psychotherapy taking so long. But the time it takes gives us the time to adapt. In retrospect, clients can look back and notice, “Wow! This time last year, I could hardly get out of bed. And now, I’m working and caring for my family.” Or “Six months ago, I could not walk into a grocery store. But this year I went to my work’s Christmas Party.”

A woman holding and looking into a small round mirror and seeing her reflection
Ketamine-assisted psychotherapy or KAP can produce relatively fast changes in one's thoughts, perceptions, and behaviors. When these changes are not managed properly, it can result in new dysfunction.

This is similar to when those who suffer from addiction gain sobriety. The lack of mental health symptoms allows us to see the world through a different paradigm. It allows us to see hope and possibility. But there is also the loss, and in some cases, wreckage left to contend with. For example, one might dwell on the lost opportunities due to depression. The paralysis from anxiety. And the effects on others. Rapid recovery from depression and anxiety will often lead right into a grieving process—which is healthy—but hard.

It can be scary to get better

Dr Steven Levine states, “Even a magic bullet leaves a wound that requires time to recover.” And what is the salve for that recovery? We circle back to the obvious: Social support and some type of ongoing therapy. People experiencing relatively sudden improvements in mental health must be able to practice interventions which maintain health. They must unlearn patterns and behaviors that no longer serve them. They must learn how to be, and stay, healthy. To live life to the fullest. (To see what social support can accomplish, I encourage you to read Chapter 15 titled “We Built This City” in Johan Hari’s book, Lost Connections.)

Ketamine is a catalyst and therapists control the reaction

Rather than seeing psychedelics like ketamine as something that erases negative symptoms, what if we looked at them as slim little tools that we slide under the big rock to get it rolling downhill? In other words, things to be leveraged to get the hard things moving.

Maintaining the effects of ketamine begins with, again, circling back to the obvious: Comprehensive lifestyle change. In his book, The Depression Cure, Dr Stephen Ilardi provides six simple but often challenging ingredients that combat negative mental health symptoms. They include:

  1.   A healthy diet (specifically omega 3s),
  2.   Disrupting ruminating thoughts,
  3.   Exercise,
  4.   Sunlight (and vitamin D),
  5.   Social connection, and
  6.   Sleep.

Therapists slow the change down. (For you cynics, this is a feature, not a bug.) Therapists allow their clients to process through the grief and loss of their close companions, Depression and Anxiety. This includes the grief and loss of the damage they’ve done. To illustrate: Have you ever read the letters which people write to let go of their Drug of Choice? They are raw, intimate, and heart wrenching: https://multiconceptrecovery.com/a-goodbye-letter-to-my-addiction/

Depressed states and feelings of sadness and anger are different from diagnosable clinical impairments

To my clients: This is similar to how we encourage you to turn towards the challenges in your ketamine therapy journey. It’s no longer about getting rid of the symptoms. Rather, develop a curiosity about them. Ask why they were needed. Thank them for their service. But then honorably discharge them from their duties.

So I still have to do therapy?

Here’s an analogy that may provide an answer. Let’s say you’re a relatively healthy human with no major physical impairments. Like many, you may feel a bit out of shape. But theoretically, it’d be possible for you to walk from wherever you are to the Grand Canyon. For most, it would take an enormous amount of effort and time, but you could physically do it. But what if, once you got to one edge of the Grand Canyon, I told you, “Now, walk to the other side.”  That would be impossible. Ketamine (and other psychedelics) might get you across the Grand Canyon. But once you’re on the other side, you have to keep walking to get to your destination.

Confidence to tackle the next set of challenges

I had worked with a very successful, high functioning client who had been in and out of therapy for the majority of their adult life. Each phase of therapy worked through bits and pieces of their childhood developmental trauma, with great success. We’d been working together for three years, making a lot of progress. But the work was arduous, exhausting and could wipe out my client for days. After a particularly difficult session, my client said, “Does this shit ever end? Am I ever going to stop feeling like I’m taking two steps forward, one step back? Will I ever actually get ahead of the game?” We would laugh together as the therapist-client trope dawned on us: Does it ever end?

Enter ketamine; stage left.

After each ketamine infusion, we would see each other to discuss the truly extra-ordinary impact that the medicine had. We traveled to a place where all the insights of past therapies were imprinted indelibly onto his body, soul and psyche.

“I feel like everything I’ve ever worked on has been touched. I could see where healing had happened. I could see where healing was continuing to happen. I knew I wasn’t done [with self-improvement]. But I also knew it was going to be OK. I knew that I was going to be OK and I was on the path I was meant to be on.”

My client then turned to me and said, “But you know what the scary thing is? In spending all this energy just to make it through everyday life, I’ve always put aside the issue of whether my partner is who I want to be with for the rest of my life. I am not looking forward to looking at that…”

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