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Ketamine is becoming a popular antidepressant, but how can those who use it retain its benefits and receive long-term depression support? At the Sage Institute, an Oakland-based non-profit providing sliding-scale therapy, Madrone Love and Angela Allan (therapists in training and the authors of this article) found that providing an Interpersonal Therapy Group (IPT-G) was an effective form of adjunctive care for clients who were receiving ketamine for depression. The group IPT-G Depression Group for Ketamine Clients happened in January 2021 and was hosted on Zoom due to COVID.

We chose to run an interpersonal therapy group because it focuses on relational issues. Findings have indicated that Interpersonal Psychotherapy Groups (IPT-G) are effective in treating major depressive disorder and dysthymia (MacKenzie et al., 2001). We also wanted to run a group because we hoped that hearing from other ketamine clients would normalize the experience of receiving ketamine-assisted therapy for depression.

What Is IPT-G?

An Interpersonal Therapy Group is a highly structured treatment developed in the 1970s by Gerald Klerman and Myrna Weissman. In 2016 the WHO published a modified manual of IPT-G for depression: Grief and Loss, Isolation, Role Change, and Interpersonal Conflict. We met with each potential client on Zoom for an intake session in which we helped them formulate a goal in one of these domains. “Making friends” could be a goal in the category of “isolation,” and “repairing my relationship with my dad” could be a goal in the realm of “interpersonal conflict.” IPT-G involves clients self-assigning homework each week to work on their goal, so formalizing a goal at the beginning of the group is an essential step.

We ran the 90-minute group sessions for eight weeks on Zoom, and the cost was relatively affordable, at $20 per session. We decided on a low fee in order to increase accessibility to low-income ketamine clients.

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Establishing Group Agreements

We capped the group at eight participants in order to maximize feelings of trust and intimacy. Ultimately five participants enrolled in this group. Before the group’s first meeting, we sent participants a list of group agreements. These agreements identified the importance of showing up on time, maintaining other members’ privacy and anonymity outside of group, and challenging oneself to participate more if one is usually quiet, or to make space for others if one usually talks a lot. Addressing the potential for microaggressions, we asked members to discuss transgressions with the group, or with us as facilitators if sharing with the group felt too uncomfortable. We hoped these agreements would foster a sense of relative safety within the group while also inviting members to be engaged in self-awareness. At our first group meeting, members discussed the agreements. While this part of the process is not mentioned in the IPT-G manual, we thought it was important to make sure everyone was on the same page.

A Structured Format

We followed the IPT-G manual’s instructions for managing the group, with minor adjustments. Participants completed the Beck Depression Inventory (BDI) each week before our meeting. This was important because it helped clients monitor their depression and keep track of any changes they may have experienced. Each session followed the same general format. After a 5-minute grounding meditation, we allotted 15 minutes to check in with everyone and ask about changes in depressive symptoms. Next, we allocated 20 minutes for three individuals to go more in-depth about any problems arising in their daily life. Specifically, we asked them to talk about what happened over the past week and how those events and circumstances impacted their mood. If appropriate, clients identified how the issues that they brought to the group related to their pre-selected focus domains of grief, role change, interpersonal dispute, or isolation. The 20 minutes allotted per individual also included time for the group to offer feedback and support. We closed the group by providing 5 minutes for homework setting, in which clients assigned themselves tasks based on their goals. There were three group sessions where we allotted 20-30 minutes to a group discussion focused on participants’ experiences with their ketamine treatment. During these groups, only two group members did in-depth check-ins.

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The Strengths of Interpersonal Group Therapy

The strengths of the IPT-G model were its structured time limits, its emphasis on group members being integral to each other’s healing, and its focus on solutions. The structured time limits helped ensure that group members received relatively equal amounts of individualized attention. The time set aside for group members to provide input and show empathy allowed us as therapists to take a back seat and brought forth the natural fount of compassion and wisdom the group already possessed. The socializing and empathy felt especially poignant given that the group occurred on Zoom during shelter-in-place. The solution-focused format of IPT-G helped group members identify specific goals and reinforced the message that they were each active participants in their own recovery. They were also more likely to focus on their goals knowing that they would need to report back each week, and that multiple people were there to hold them accountable.

“The strengths of the IPT-G model were its structured time limits, its emphasis on group members being integral to each other’s healing, and its focus on solutions.”

Adding Flexibility to the Format

The main limitation of the IPT-G model was its rigid approach to interventions. The interventions described in the IPT-G manual are Communication Analysis, Decision Analysis, Role Play, and Interpersonal Skills Building. Communication analysis involves gathering details about interpersonal challenges and decision analysis entails helping a group member think through a difficult decision. Role play is described as helping a client act out a recent or planned conversation, and interpersonal skill building requires the group facilitator(s) to teach group members interpersonal communication skills. These standardized interventions ensure that IPT groups are easily replicated. The manual is designed to be easy enough for any community leader or medical professional to implement, even if they’ve never received training in therapy. We tried to employ these interventions in the early stages of the group, however, we found that employing more client-centered therapeutic techniques, such as reflective listening, empathy, and open-ended questions, was more helpful than strictly adhering to the interventions described in the manual. Straying “off-script” allowed us to be more flexible in meeting client needs.

Another change we made to the IPT-G format was the addition of 15 minutes after check-ins for clients to talk about their ketamine protocols and to ask each other questions about ketamine treatment. Protocols ranged from in-office ketamine intramuscular IM sessions accompanied by mental health providers, to at home ketamine lozenge sessions. Each client’s protocol was unique and had been designed by the client’s psychiatrist or mental health provider. This yielded fruitful discussion, because psychiatrists and ketamine clinics who provide clients with ketamine follow different protocols, and it can be helpful for clients to know how treatment protocols vary. Knowing about alternative approaches gives clients the power to advocate for a change in their own treatment if they believe they are being under or overprescribed. We also noticed that taking time to focus on discussing the ketamine component of the therapy helped normalize the unusual experience of being on the drug, and fostered group cohesion.

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A Solution-Focused, Community Model

Throughout the IPT-G Depression Group for Ketamine Clients, we noticed that clients responded positively to the group format and expressed appreciation for the solution-focused nature of the group. While many psychedelic integration groups are not goal-oriented, we found that adding a homework element helped clients establish and/or maintain a sense of agency over their own wellbeing, as well as work toward healthy behaviors throughout the week. The built-in “homework check-in time” also fostered a sense of accountability, which was conducive to clients meeting their goals.

The primary benefit of the group appeared to be the community of support among like-minded people, which developed over the two-month period. It was heartening to witness participants quickly become sources of care and inspiration for each other. The opportunity to discuss ketamine treatments helped clients feel that they were not alone, which was important because ketamine is still a stigmatized and misunderstood drug. Participants could also vent about frustrations they had with their ketamine treatment and receive much-needed empathy and support.

Suggestions for Future Groups

We believe the IPT-G format is appropriate for clients choosing to take ketamine to treat their depression and may even be more effective in-person. To future practitioners who would like to facilitate a group, we recommend establishing group agreements, starting each group with a grounding meditation, being flexible with the types of interventions offered, and providing time to discuss ketamine protocols. We also recommend soliciting feedback from clients about their experiences regarding culture and diversity in the group. While we had a felt sense that clients were openly sharing about a wide range of their experiences, in hindsight we believe that directly asking clients about their experiences of diversity and inclusion in the group could have generated useful feedback. We recommend that future clinicians find ways to generate this feedback during and after the course of their group. 

“As we move from a model of individual healing to collective healing, we may see a resurgence of therapy groups. The benefit of IPT-G is that it is simple and straightforward, and the real magic comes from the natural empathy, humor, and wisdom that individuals bring to the sessions.”

As we move from a model of individual healing to collective healing, we may see a resurgence of therapy groups. The benefit of IPT-G is that it is simple and straightforward, and the real magic comes from the natural empathy, humor, and wisdom that individuals bring to the sessions. Psychedelic healing in the holistic sense requires community, and it was an honor to foster community, even in a time-limited, Zoom-centric way.


References

MacKenzie, K. Roy. Grabovac, A.D. Interpersonal Psychotherapy Group (IPT-G) for Depression. The Journal of Psychotherapy Practice and Research. 2001; 10:46-51.

Art by Trey Brasher.


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