Supercharging Couples Work with Ketamine

A Doorway to Greater Intimacy

Magazine Issue
May/June 2024

While MDMA, psylocibin, and LSD are still on hold with the FDA (though not for much longer it seems), ketamine, a long-prescribed “anesthetic with psychedelic effects,” has become the go-to drug for therapists eager to help their clients experience psychedelic healing. At this moment, it’s the sole psychedelic legally available across the country for clinical therapy use, and it’s been proven effective at moderating trauma symptoms and helping reframe our relational experiences.

Having spent my whole career as a couples therapist looking for new ways to help clients create the meaningful, lasting changes they’re seeking, I joined two dozen fellow therapists a few years ago for a ketamine-assisted psychotherapy training. I had high hopes that ketamine—whose effects dissipate after about two hours—would provide a manageable treatment option for clients needing the sort of psychologically revelatory experience that can shift deeply entrenched patterns in their relationships.

After weeks of educational training about ketamine’s risks and benefits, I was eager to experience the effects of the drug myself. Dosing over the five-day retreat would be determined by a prescreening with an MD and a consultation with the therapists leading the retreat. (While ketamine can be risky, as evident in the recent death of actor Matthew Perry, participants were given far smaller doses than what Perry himself was self-administering at the time of his death. Also, Perry wasn’t under supervision at the time and shouldn’t have been in a hot tub while taking a drug that creates a dissociative effect. The risks of ketamine are real and should be monitored by a professional).

A few of my fellow clinicians had shared that they’d had a negative history with psychedelics and were ambivalent about trying ketamine. I understood. Some of my own recreational experiences with psychedelics had been scary too. But I felt confident that the retreat’s benefits would outweigh any negative experiences.

The retreat was created to be a safe space for therapists to experience the ketamine in several doses, and we were mindful of two factors that are considered highly impactful during psychedelic journeys: “set and setting.” Set refers to your mindset and includes feeling confident about your intentions; setting is the physical space where you are, your surroundings—in our case, the room we were in and our trainers and colleagues.

First, I and the other therapists, nurses, and doctors on the retreat shared our intentions for our upcoming journey. “I’d like to know what my next step is in my mission of helping others,” I told everyone. “And what I need to do to get there.”

We each had a soft mat, a pillow, and a blanket so we could be warm and comfortable. A personal psychotherapist guide, known as a sitter, would watch over each of us during our journey, recording anything important we might want to note in a journal. In addition, several lead facilitators would be present to model how to create a cohesive and safe ketamine experience for the group.

“Each of you will have two journeys over the course of the next few days,” our facilitator told us. “The first will be with a ketamine lozenge, and the second with a higher dose of the drug, given intramuscularly. Our doctors and nurses will provide the doses, and the therapists and assistants in the room are going to be with you the entire time, so feel free to raise a hand if you need something.”

The room filled with soothing music from a playlist curated to accompany us through the phases of our journey. Now, it was soft and slow, but we’d been told it would shift into different rhythms and intensities later to bring us deeper into more challenging experiences. When it was time to return to regular consciousness, the music would soften again, signaling that our journey was ending. Our sitters took their seats and reached for our journals, ready to record.

“Breathe softly,” my sitter said. She was a counselor from Vermont and had an easy warm smile. “I’ll be here whenever you need me and am happy to hold your hand if you’d like. Just ask.”

I nodded and returned her smile, placing a 250-milligram lozenge in my mouth and lowering over my eyes the mask meant to help us focus on our internal experience. For the lozenge to be absorbed properly, we had to swish it around in our mouths for about 15 minutes. It had a strong, bitter taste that an artificial cherry flavoring couldn’t cover: not unpleasant, but not delicious either. After the allotted time, some people spit whatever remained into a cup, others swallowed for a deeper experience, which might last longer but could trigger nausea. I tend to get sick in cars, boats, and planes, so I was given the nausea preventative Zofran before we began.

I chose to remain seated while swishing the lozenge around in my mouth, and at one point, I raised my eye mask to find that everyone else was lying down on their mats, apparently relaxed. Some were moving to the music. At the 15-minute mark, once I swallowed the remains of the lozenge, I lay down and relaxed too. Almost immediately, a numbing sensation spread from my mouth into my torso and down my legs—which I took as a sign that the analgesic was taking effect.

I began to have visions. What surprised me most about them was their verticality. The ceiling opened to an endless sky, and I instantly understood that the world of ceilings and walls was an illusion—a narrative we humans have made up and decided, en masse, to call reality.

As I thought this, other versions of what I considered reality began falling away. Time seemed irrelevant. I no longer had any sense of my body, and I let go of my attachment to any personality that resembled me. The vertical visions sank closer to my eyes. I briefly thought I was looking up through dirt: that maybe I’d been buried alive. You should be concerned about this, I told myself. For a claustrophobic like me, any enclosed space can be nightmarish, but I didn’t feel the fear. Instead, I thought, If this is what being buried feels like, I could be okay. In fact, I am okay. It dawned on me that our life here is just one of many incarnations and experiences in the vastness of existence. With that thought, small cracks of light appeared in the dirt above me, which then turned into stars in the sky, and helped bring home a profound sense that the world is truly vast, beyond measure.

After the visions wore off and I’d come back to my mat and steadied myself, I tried to explain my experience to my sitter but found I couldn’t. It was like there was no language for translating the vastness of the experience I’d had. It felt like the part of my brain that makes meaning and language was offline. It took some time for that part to come back online and reconnect with the observing part of me.

A Stupid Question

Two days later, I was back on my mat for my second dose of ketamine, along with the other clinicians who’d gone through a ketamine journey alongside me. Excited to return to a world of expansive realizations, I yanked my eye shade down in anticipation of what lay ahead. To say I felt safe didn’t do justice to the emotion of that moment. Here I was in a community of responsible, deeply informed, like-minded seekers who were looking for a way to help heal others. It felt meaningful on a personal level, as if I was part of something greater than myself.

Trusting that I’d be okay, no matter what, was a new feeling for me. As the oldest in a family of three, I often felt alone as a child. I was overly responsible—an adaptive response to navigating life with my single mother, who was in a perpetual state of deep grief due to the many losses she’d suffered while working two jobs to support us. She’d been unable to provide the safety I needed to believe that the world would nurture and hold me. From an early age, I’d craved something magical to give me that kind of assurance. And now, finally, in this room, all these decades later, I was awakening to an inner intelligence showing me that we’re never alone; we’re always and inherently connected with something much greater than ourselves.

Psychedelic-Assisted Psychotherapy for Trauma

Most everyone who has been on a psychedelic trip experiences a sense of awakening to a connection that’s the opposite of aloneness. What a gift for ourselves as healers, and for our clients! Such knowledge can reduce or even eradicate our sense of isolation and help us transcend chronic grief. The question for those of us wanting to incorporate these trips into our practice is, does this knowledge last? Can we sustain it and integrate it into real life, go to work, do laundry, pay bills?

This time, when the music began to play, the group leaders walked slowly through the room while the sitters settled in. I lay down on my mat right away, and a nurse delivered the intramuscular shot to my arm. Mere minutes passed before I was on a fast ride through a world of brilliant kaleidoscopic colors and shapes. This other land became vertical and many-layered, pulsing with a phantasmagoria of blues, reds, oranges, and yellows—a kaleidoscopic experience I now know is called synesthesia, where sound takes on substance, becomes mobile, and evokes colors and shapes. The landscape moved in sync with the music, and I soon lost any sense of myself as a body, or even as a person. I didn’t know where I was or if I’d ever return to the room or myself. Rather than panic, I accepted this new reality as my home—one I’d always known. In fact, any other reality was simply an alternative parallel universe, which existed only because I’d made it up. In this new real life where I belonged, I lost all sense of time and space.

As the sensory roller-coaster ride began to slow down, I remembered my intention and managed to ask my original, professional question: “What’s my next step on my journey to help others?” Immediately, a force that seemed to exist outside of me said, “That’s a stupid question.”

I understood this to be the universe telling me my question didn’t matter because the millions of decks of cards I now saw spinning around me were all lifetimes happening simultaneously. Each card in the deck was another version of me, and I could choose a new version or not; it didn’t really matter. In this multiverse, propelled by quantum mechanics I couldn’t understand, my intention to know my next step on my mission had no meaning whatsoever.

After about 60 minutes, I came totally back into the room, sat up, and took off my mask, feeling dizzy, confused, lost, and excited. The first thing I said to my sitter was, “We’re really giving this to patients?”

The Aftereffects

For two weeks after my retreat and the two ketamine experiences, I felt sluggish and tired. I had very little ambition and no motivation to accomplish anything. Mostly, I slept, doing the minimum amount of work I could to get by. I wrapped myself in warm clothes and avoided saying much to anyone, including my husband. I cried a lot. Then my training group met for our integration call on Zoom.

“I have no motivation to do anything,” I said when the facilitator invited me to speak. As I observed the faces on the screen nodding kindly, I realized that a profound and deeply meaningful shift had occurred. I was no longer propelled to move at the same pace I’d been moving at before, racing from one thing to another, something I’d done all my life. My overworking, my addiction to busyness, my constantly packed schedule—all of it had stopped.

“I’m seeing how my workaholism was a survival skill from childhood,” I shared, crying as I spoke. “It was a means to survive a depressed and absent mother and a means to an end. I didn’t want to be poor and end up in the same circumstances I was raised in. I’ve been pushing myself, from the time I was young, to take care of everything, to keep going, no matter what.” It was like I’d been driving a pickup truck my whole life and stepped on the brakes and everything in the cargo area had smashed into the back of my head.

After that integration call, I began sharing more with colleagues, friends, and my husband about how I’d compensated all my life with work, with a desire to be busy. I talked about my childhood more than I ever had before. I even revisited the idea of writing a memoir, something I’ve wanted to do for years. Although I’m back in my busy life, now, the pressure to perform is gone. I’m looking at drafts of the book I could never finish and seeing them fresh. I’m appreciating my life in a different way. I’m no longer afraid of starving if I slow down my schedule.

Not everyone’s experience with ketamine is like mine. Some people go to darker places, and others just have fun bouncing around in that kaleidoscopic world. But it’s said that ketamine brings up all the things you need to work on, and I believe that’s true.

Ketamine Retreats

I now lead ketamine retreats for couples, and it’s a great fit for the work I do integrating relational therapy. The combination of therapeutic guides, ketamine, and community is game-changing for people. Since I believe all couples in all forms of relationships are looking for a deeper relational experience, I call what I’m doing with couples Ketamine-Assisted Relational Therapy.

In a workshop or retreat setting—as opposed to a siloed, isolated couples therapy office they visit once a week—couples often have added motivation to work toward change. They’ve invested time and money to be there, and it can feel like a vacation from the everyday morass they’re caught in. Although therapists can work with ketamine in their own office, I like the feeling of creating and sharing a group ritual with others around the ketamine experience. I sense that we all, as humans, are looking for our community, which can be found in the retreat group experience. The whole process is geared toward experiencing change. But does the change last after participants go home to their everyday routines?

With the promise of integration and follow-up after ketamine, people leave feeling more connected with themselves and more able to share themselves with their partner. Research shows a solid month of dendritic growth occurs after a single dose. That’s a long plasticity window! It can give couples the time they need to translate their insights into actions, and for those actions to evolve into new habits.

This was the case with Harper and Ava. They came to one of my retreats to reconnect—or as Ava put it, “to connect, period.” The ketamine allowed Ava to feel something beyond the limited space she occupied as her constructed self—the one that was a partner to Harper, a daughter of a critical mother, and a hardworking policy activist. She’d taken a low dose, so she could still communicate during her journey, which centered on feeling truly alive and part of something bigger than herself. With her eyes closed, she put one hand over her chest and reached for Harper with the other. “This right here,” she said, squeezing Harper’s fingers, “is all I need. I’ve been searching for something, for everything, but I have it all, right here.”

During our integration process, she shared this realization: “My constant searching for something else outside of our marriage has caused this loneliness for us. I was looking for a way out, but I realize it wasn’t a way out of us that I wanted: it was a way out of my childhood. I don’t need a way out of us. I’m perfect right where I am.”

The ketamine allowed them each to experience a unique internal journey, where they met their own medicine and reframed the meaning of their own narratives, which they discussed afterward with each other and the therapists. Harper got better at hearing her without getting defensive or shutting down. During her journey, she’d realized that her childhood of neglect had created a wall around her, one she’d never even let Ava breach. “I always felt that Ava had one foot out the door, and now I see what she was doing: creating an outpost for the inner child that needed an escape. I saw her in my journey as a kid who needed a tree fort, someplace to hide outside of our house. I can give her that without freaking out that she wants to leave me. I get that she needs space, and it’s okay. She still loves me.”

For the rest of the retreat, they ate healthy meals, took walks, and shared more of their experiences with the other retreat members. Meditation and yoga and music sessions helped them continue processing throughout the retreat. I often saw them holding hands.

Could we have gotten to this place without a ketamine retreat? Sure. But it likely would’ve taken several months, or even years, of work in therapy—provided neither of them got frustrated and dropped out. After the retreat, Ava and Harper followed through on a commitment to have honest conversations daily, even if they occasionally hurt each other’s feelings. They began showing up for each other differently. I attribute this openness to change to the residual effects of ketamine.

Should we give all our clients with challenging relationships psychedelics? Absolutely not. The medicine itself is not a magic cure for relationship issues. Lasting change emerges from the integration of the experience with therapy. And the experience can be complex. Ketamine can create hallucinations and out-of-body experiences, leaving people feeling unsettled and lightheaded. That’s why the treatment needs witnesses and guides who can provide containment and ongoing support for individual as well as relational transformation.

For therapists in the experience, ongoing supervision and consultation are critical. Dosage matters, too. When working with couples, treatment should start with low doses, which can create more awareness and allow for more communication between the partners and the therapist.

Creating a New Narrative

During a ketamine journey, because you dissociate from your concept of being in the here-and-now and lose the feeling of self, the part of your brain that makes meaning—your midbrain—can shut down temporarily. Your observing ego either recedes into the background or goes silent. This can be scary for people who want to make meaning of the moment because the ego is trying to decode the experience: I have to remember this. I have to understand. I have to know what’s happening to heal from my trauma. But sometimes we don’t have to try so hard to understand. Letting go of the observing ego we’ve grown so attached to can itself be the therapy we need. Then, our wiser self can guide us through metaphor, felt experience, and deep insights into new learning.

A ketamine journey can help us let go of our narratives—about our lives, our childhoods, what it means to be in relationship, to be a certain gender, to be gay or straight, to argue, to love. This process begins with understanding how and why we’ve concocted a narrative in the first place. We can understand and assert control over our narratives and what they mean only when we realize we’ve been making up these stories all along. Then those narratives need to be grieved. For clients, this grieving can lead to the creation of a new idea of connection and partnership. For Ava and Harper to embark on a new story of themselves as more than a couple who cohabited and were polite to one another, Ava had to grieve a story she’d been telling herself for years—that what she needed was always eluding her—and Harper had to grieve her story that if she didn’t hold tight to what she loved, she’d lose it. Their new vision of their relationship acknowledged their needs for space, intimacy, and adventure.

All this may sound daunting, but with ketamine it’s possible to move through the process fluidly and naturally. We don’t need to do much digging or conjuring: the drug brings us face to face with our stories, as the narrative of our world is laid out in metaphor, imagery, and emotion. In some ways, this resembles dreamwork. Clients experience their world and how they inhabit it, and then they shake it up and put it back together in brand new ways. Ketamine might not be the answer to healing all trauma, but it often reshuffles it in a way that allows people to see the battles and perpetrators in their lives with fresh eyes. Through this reshuffling, they can find empathy for themselves and their partners, and meaning in their shared world experiences.

What’s Next?

I’m not alone in my excitement about psychedelic treatment, but the general enthusiasm in our field is interesting to me, given how frightened we tend to be of non-ordinary states of consciousness in therapy. When clients tell us stories of hearing voices or receiving messages from beyond, we’re quick to label them as psychotic, give them a diagnosis, and load them up with medications. Generally, we discount spiritual experiences in sessions—or at best, we see them as adjunctive to the real work that takes place in our offices. As a field, we’ve never given clients the ultimate power to heal themselves or encouraged them to follow their own inner guidance. We’ve trained them to rely on us as the experts on them, assuring them that with our intelligence, our privileged healer powers, education, experience, and evidence-based solutions, all will eventually be well.

But will it?

Maybe interventions with psychedelics are a way to access a kind of healing that we, as verbal treatment providers, can’t quite reach. Despite my deep awareness that we risk commodifying something that’s been part of many cultures as a ritual, religion, and belief system for thousands of years, my hope is that the current psychedelic movement reminds us that there’s inner wisdom in all of us. Therapists can partner with that wisdom as a directional marker, one that provides guardrails when clients veer away from the guidance they’re receiving from within themselves, and perhaps from somewhere far beyond our own understanding.


Tammy Nelson

Tammy Nelson, PhD, is an internationally acclaimed psychotherapist, Board Certified Sexologist, Certified Sex Therapist and Certified Imago Relationship Therapist.  She has been a therapist for 35 years and is the executive director of the Integrative Sex Therapy Institute.  She started the institute to develop courses for psychotherapists as the need grew for certified, integrated postgraduate sex and couple’s therapists in a growing field of mental health consumers who need more complex interventions for their relationship needs. On her podcast The Trouble with Sex, she talks with experts about hot topics and answers her listeners’ most forbidden questions about relationships. Dr. Tammy is a TEDx speaker, Psychotherapy Networker Symposium speaker and the author of several books, including Open Monogamy: A Guide to Co-Creating Your Ideal Relationship Agreement (Sounds True, 2022),  Getting the Sex You Want: Shed Your Inhibitions and Reach New Heights of Passion Together (Quiver, 2008), the best-selling The New Monogamy: Redefining Your Relationship After Infidelity (New Harbinger, 2013), When You’re the One Who Cheats: Ten Things You Need to Know (RL Publishing Corp., 2019), and Integrative Sex and Couples Therapy (PESI, 2020). Learn more about her at