Clinical Interventions and the Intentional Use of Relationship in Ketamine-Assisted Psychotherapy

Dr. Sandy Newes 21:17

oh, like, well, and for me, that it’s been helpful to realize that that particular piece is also something I have felt in traditional psychotherapy, especially when I was newer in my career, like I’ve got to be a value. I’ve got to prove that we’ve got to get there now, so that they can really get what they’re coming forward, you know, and not recognizing that the relational com that can lead people to not feel safe either one they’re pushed or two, but just to go land in, like, the place of attunement, like, you know, it takes us back to that relational piece about the importance of attunement,

Jim Hopper, PhD 21:51

yeah, and, and so, yeah, as you were saying, it can happen to people who are new and young as therapists, but then there’s the other side, Someone who’s a very experienced therapist, and they’re so confident in their methods and everything. Or maybe people get attached to a particular model, and you know, then you can overestimate, you know, your knowledge of what they need right now and things like that. So, you know, at any age, any level of experience, there’s these are potential, I know it’s

Dr. Sandy Newes 22:19

right for you, and, yeah, and,

Jim Hopper, PhD 22:21

you know, and, you know, while I totally appreciate the relational aspect, sometimes people do need a little more, I think, and don’t, don’t need someone in there with them, talking to them the whole way through. But you know, who am I to say? Like, it’s all different context and relationships and everything. But you know, that’s something that I feel like I’ve seen too sometimes, is that the relational mode can actually lead people to relate to someone in a way that they’re like, whoa, that’s too much. I need more space here.

Dr. Sandy Newes 22:50

Yeah, I’ve probably been guilty of that at times just like, well, we

Jim Hopper, PhD 22:55

all have our we all have our things, right? We all have our things. And some of us maybe go back and forth between these polls. Sometimes it’s tough therapy stuff. It’s not just about the medicine sessions, but they can really supercharge it because of the vulnerability, the suggestibility, the things that can get stirred up. So then these dynamics can get very powerful very quickly.

Dr. Sandy Newes 23:16

Well, let’s talk some more about that. So you you know, you talked about empowerment and connection, and then you talked about, you know, that those being core tenants of trauma, informed care in this way. And then you also talked about the relational aspect. So we’ve, obviously, we’ve been talking about the relational aspects, but just kind of like, you know, highlighting that about what you just said about the relational dynamics, you know, and at that point we’re talking about transference, we’re talking about safety. But, you know, there’s a lot of different things that that means. So can you say more what you mean by that? And you know, just with what we all what you think we should all be attending to, really, I mean, that’s a huge question, yeah, that’s a huge grammar. And go from there,

Jim Hopper, PhD 24:00

yeah. But, you know, some of the things that I think are, you know, I was trained in the psychodynamic tradition, so there’s a lot of attention, you use the word transference, you know, there’s a lot of attention to transference and counter transference, and these relational dynamics and our vulnerability to reenacting early relationship patterns, you know, with our clients, you know, ones that were harmful, and the need to recognize that and repair when it happens. So for me, like fundamental is really trying to be humble and honest with myself about, like, what might be getting triggered in me, what might my motivations be? And so really attending to what’s motivating me to relate to or even think about a client in certain ways? Obviously, you don’t want to, you can’t be meta, obsessed with this stuff all the time, or you won’t be connected. But just try to have kind of this sense of like, you know, checking in about like, well, what’s my motivation here to say? This or, or the way I’m interpreting what they’re doing. So a lot of it is, you know, having self awareness of, you know, your own tendencies, your own vulnerabilities, that sort of thing. And then, you know, if it’s an ongoing relationship with a client, really learning from that relationship and, and what are the dynamics that are happening, and how can you, how can you work with those skillfully? How sometimes do you need to step back and reflect on those together with the client? Those are some of the key things that I find helpful. But there’s so much more we could say about it, but those are a few. Yeah,

Dr. Sandy Newes 25:36

well, but I think what I think as you say that what grabbed my attention when I first heard you talk that way is, again, when we speak it, just say it like, it seems obvious, but I think I just realized that where I think that is so important is, again, with this emphasis, and people thinking it’s all about the medicine, and not having the realization, you know, and That becomes really relevant when we’re talking about, like ketamine specifically, like ketamine clinics that are run by anesthesiologists. I know there are many lovely anesthesiologists, but they’re also people making broad mental health claims about treating trauma and PTSD with just the medicine, yeah, and so, you know, just kind of that’s really different than what you’re saying,

Jim Hopper, PhD 26:22

yeah, and unfortunately, you know, we’ve heard from people who, you know, some people go to an infusion clinic and they get a lot of benefit and they’re not getting any therapy, but some people go to an infusion benefit clinic and they’re not getting much benefit, and not only that, but they may be suffering harm. They may on the medicine. They may get flooded with memories, recover memories, relive experiences of abandonment, especially you think you know you got this IV in your arm, and maybe people are in another room and they’re just monitoring you over a camera or something like that, that can really stir up people’s memories and old experiences of neglect and abandonment. So I’ve had definitely people who’ve been to those clinics, and because it was not within a therapy relationship, they were on their own, on these medicines, essentially, and they suffered some really negative consequences. So you know that can happen worst case scenario, but unfortunately, it does happen sometimes. Yeah. So what we’re talking about is totally different. It’s ketamine assisted psychotherapy, right? Ketamine assisted trauma therapy. And so the medicine is brought in very carefully, very slowly, to work into a relationship that’s already there, a healing process that’s already going on, and to then try to facilitate what the client is seeking, what’s already emerging in the therapy, I would say,

Dr. Sandy Newes 27:50

yeah. I mean, for for myself, I do a lot of I’ll do, I don’t just do single cap sessions very often. I do series, generally, between three and six over a period of time. And, you know, I do three to five integration or three to five preparation sessions before I even start. And you know, that’s just so different than, like, going into a clinic, and, you know, just, just getting hooked up to ketamine. And, you know, it’s, like, it’s, I call it meat and fruit, like, it was just very, very different. And I, you know, I think this relational piece is so important. So, you know, how can clinicians do a better job? Like, if we’re, you know, we want to do well, we want to do this relational piece Well, you know, we’ve already been attending to what you talked about earlier. You know, the competency and the empowerment. We’re making sure that people aren’t getting like overwhelmed by being abandoned, or we’re not overly dominating them, kind of but how do we do good relational work with psychedelics?

Jim Hopper, PhD 28:55

Again, it’s a big question. One thing I would just say is distinguishing between whether you were working with your own ongoing client, or are you working in an adjunctive capacity. And one thing that we really learned from the MDMA study, and my colleagues and I say we, you know, those of us in the Boston area who were therapists on that and who do peer supervision together in ketamine assisted therapy, is that we’re not going to do adjunctive ketamine work with anyone, unless they already have a solid relationship with a primary therapist and they have a solid relationship with someone who’s going to be able to support them with whatever might emerge in the ketamine work Now it doesn’t mean we don’t take if we’re going to work with them, of course, we’re going to do the preparation. Work. We’re committed to helping them integrate what comes up too, but to just do it adjunctively, or to just do it with someone who doesn’t have an ongoing therapist, especially if there’s significant trauma involved, we found that that’s just not safe, and so that’s one. Thing you know, if you’re working adjunctively, what kind of primary relationship does the client need to have with a therapist, and what kind of communication do you need to have with that therapist? So it’s really a team effort. And so because if their therapist is like, oh my god, sick of dogs, that’s crazy stuff, right? And that’s not the best conditions for working as an adjunctive therapy in that situation, and then with our own clients, you know, it might, it might be years before we introduce a medicine, you know, offer the opportunity of a medicine session with someone. And so, just to make that distinction between, like, is it adjunctive, or is it someone you’ve been seeing ongoing for a while, and now you’re potentially going to introduce medicine work into that.

Dr. Sandy Newes 30:44

So adjunctive, you mean, somebody refers, or they come into your office and they’re like, I just want to do cap. I want to do ketamine. I already have a therapist, or you’re assessing to see if they do,

Jim Hopper, PhD 30:54

yeah. Or someone who just wants to, they say, Oh, I just want to do a little bit of ketamine therapy. You know, ketamine assisted therapy, or they might even call it ketamine therapy, because they think it’s all about the medicine, right? But they want it, you know? They want to, oh, I’ve been here with this ketamine, you know, I don’t do anything illegal, or, let’s do ketamine and, and so, you know, a lot of it is psycho education to just help me think about how this is ketamine assisted psychotherapy. There’s preparation, there’s integration, but then also, okay, do you have a primary therapist? What’s your relationship with like with them? You know, have you had difficult patches that you’ve gone through together already with them and came out the other side pretty well? So that’s, you know, part of the education and assessment process. So someone’s just saying, hey, I want to do some ketamine assisted psychotherapy. Okay, do you want to come my ongoing client and then we’ll see when we’re ready to do that? Or do you want to do a piece of work with me? Then I can’t do that unless you have another therapist who you’re going to be working with. And often, you know, I already have, I already have my long term clients. I don’t have room to take on someone in an open ended way, so I’m not going to take them on and then drop them or, or, you know, something like that. Yeah,

Dr. Sandy Newes 32:05

it’s interesting, because I used to get in trouble with that more, I think earlier I started, you working with ketamine in 2019 and when people would come in and they would want to get straight to the medicine, I would want to please them by, you know, so I would often short change the preparation, or, you know, be like, okay,

Jim Hopper, PhD 32:20

you know, I’ll get there because, you know, you’re spending money for this, and I want to be useful.

Dr. Sandy Newes 32:25

And now I’m much more clear on what the process of cap is, and also what I will and won’t short change. What I won’t short change is the preparation, you know, even if that, and then that gets tricky. If it is more adjunctive, like, do I need to take a full developmental history if somebody is already working with a therapist who has all of that? And the answer for me has landed in Yes, but that’s also extra expense for the client, and so I’m always kind of doing that dance,

Jim Hopper, PhD 32:52

but yeah, so yeah, definitely. Money, money can be an issue. These things are complicated. I don’t want to pretend they’re not. They’re not complicated, and they’re all, you know, they’re unique therapy relationships. You know, back to your question of, how do you do this work relationally? A big part of that is the recognition that every client relationship is unique, and you need to get to know each other, develop an alliance, really know and learn together, what’s going to be helpful, what’s not so helpful, and so just that appreciation for the unique individual and their unique healing process, and the unique healing relationship that you’re collaboratively building together, I think he’s definitely at the heart of working relationally with psychotherapy and especially with these medicines

Dr. Sandy Newes 33:35

well. And I think that attunement piece, you know, how can I be attuned to the client if I don’t actually know the client, like, I mean, there’s like, like, Duh, that’s a no brainer. And yet again, when we start short changing it and moving too quickly to the medicine, or over emphasizing the medicine alone without the integration of therapy, I think we’re in danger of that. So you’ve talked about corrective, relational experiences, correct. And, you know, that was like, yay. I studied object relations, and I remember kind of, you know, learning that particular term. And so how do we do as good a job as we possibly can at creating corrective relational experiences? Let’s assume, let’s assume the adjective piece. Let’s because, you know, it’s different when we have an ongoing client and we move towards the medicine like, but let’s, let’s assume the adjunctive piece. Let’s assume they have a therapist, and they’ve come to you for ketamine, right? Because that’s what you’re doing, that’s legal and and you’re going to do one or more. So what? What can you offer in terms of, like, what you do or what others should do? Like, how can we create these corrective relational experiences? Because I believe that that is the crux of the change process. Like that somebody is having a different experience of themselves and others, like, under the medicine that can shift sense of self. So how do we do that? Yeah. I

Jim Hopper, PhD 35:01

mean, again, there’s a few different things, and we can’t do them all justice. One that I find, you know, the medicine work is really helpful with because you have the longer sessions, because people are entering into an altered state of consciousness, where they’re, you know, opening themselves just, you know, something maybe beyond their usual ways of understanding or working with their experience that I have I convey this profound respect for them and and faith in them and their ability to heal and and that my role is to be supportive to something that’s beyond what I might think of. So I have a profound respect for their healing capacity and for the mystery of the process. And so I feel like, you know, that’s something that I’ve really deepened through doing the work with the MDMA and the ketamine and and that that’s often a new experience or a deepening of an experience, for clients to really feel like, wow, this person really believes in me again, not in not in a naive way, not in an over the top way, that then they feel like, Oh, my God, I had a bad session. So I fail them, and I’m not what they thought I was. That kind of thing, though, those things can come up right when people have don’t have a good session, and you’ve expressed all this faith in them, now they feel like they’ve let you down, that they’re not what you thought they were. But I do feel like that’s a fundamental part of it. Is like a foundation for the relationship, is a real respect for and faith in their healing capacity and their healing wisdom.

Dr. Sandy Newes 36:40

So having a profound faith in their healing wisdom. And is that something that you just kind of hold in your awareness? Do you communicate that a lot to them? I

Jim Hopper, PhD 36:53

definitely communicate it. Yeah, I hold it in my awareness, and I definitely communicate it, whether I communicate it a lot, I mean, that depends, like anything, if you say it can be too much, if you’re saying it too often or with too much intensity, or whatever amazing you’re so amazing. Oh, it’s always a dance and and seeing, you know, trying to feel into what’s going to be supportive to them. But definitely, I articulate those things, yes, that I have, you know, a real faith in them and their ability to heal, and and, and often that’s a faith that goes beyond what they’ve had for themselves so far. And then through the medicine work, they can get access to dimensions of their experience, of their being, of their healing potential that they haven’t had access or so. Then that’s deeply affirming. When you get that feedback loop of you have that real faith in them, and then they’re able to access it, and it can really deepen the work and open them to transformation in a big way.

Dr. Sandy Newes 37:51

And then, so then, how do you roll that into integration like that? You know, that’s another piece right? That we’re talking about preparation medicine integration. So how does that then show up in integration?

Jim Hopper, PhD 38:07

Yeah, well, I’d say in integration, you know, there’s more. There’s definitely, again, I convey a faith that it’s an unfolding process. It’s not just about what happens on the medicine, that the medicine experiences is part of the unfolding mystery of their life and their healing and to have faith that things will unfold. But also in integration, it takes more discipline. It takes, you know, focusing on certain things and relating to them in a disciplined way, trying to cultivate new habits, maybe new skills. And so that’s where, you know, I think it’s just faith in the healing process isn’t enough. It can. It really takes working with a client to help them identify some things that they’re going to work on and integrate through practice, through discipline, practice. And that could be like, you know, playing the piano more. It could be dancing more. It could be, you know, more mindfulness or loving kindness, meditation practice. It could be all kinds of different things that you wouldn’t even necessarily think of as traditionally therapeutic. But it’s not enough to just have faith in a process that actually it takes embodying new habits, habits of thinking, habits of feeling, habits of relating to your body, habits of self care, right?

Dr. Sandy Newes 39:24

It’s not all just about, like, tripping out and realizing things, I know, yeah.

Jim Hopper, PhD 39:29

I mean, you get great things from that, but it’s not right.

Dr. Sandy Newes 39:33

I mean, I always tell people, I’m like, it’s not all about the aha moment. You know? It’s not that you’re gonna, like, necessarily have, like, a profound realization that’s going to change your life forevermore. You know, it’s a lot of work about what you do with that, and even if that happens well, so, so you’ve already mentioned ways that we could do harm, but let’s just kind of revisit that again, just to kind of, you know, name that, like, you know, that was do all of the guy just came. From your right conference. And there were some, certainly some references to that, yeah, you know, how can the therapeutic relationship? You know, whether it be clinician or, you know, we know people are doing this under the underground guide or medical professional. How can we do harm like this is clients are in a really vulnerable state. So what do we need to watch ourselves? What do we need to check in ourselves so that we’d not doing that?

Jim Hopper, PhD 40:25

Yeah? I mean, there’s so many ways, right? So, um, but assuming people are, you know, generally trying to help and not, like, actively motivated to sexually exploit their clients or something, right?

Dr. Sandy Newes 40:36

Obviously, like, don’t have sex with your clients, right? Like, we know that. But beyond that in the more kind of, you know, nuanced ways, yeah,

Jim Hopper, PhD 40:45

again, some of the things I was talking about really attending to the vulnerabilities your client has to being harmed and and especially in the context of complex trauma, ways that they can get triggered, ways that They can get overwhelmed ways that they can get in relational dynamics that are re enacting dynamics of neglect, abuse, exploitation, and so just really being aware of those possibilities and and noticing them and attending to them before they spiral, if they start to begin and really attending and getting supervision from colleagues is necessary to really attend to, like, what’s getting triggered in us, potentially, where we could have, you know, counter transference, as the psychiatrist would say, you know, to our clients of, you know, feeling like we didn’t help them, like, you know, it can be our own feelings of failure that can lead us to then overcompensate in different ways, or incompetence or or whatever, or that, you know, that they’re not doing the work enough. Or, you know, there’s so many different things that we can I’m not doing enough, yeah, well, I’m not doing enough. They’re not doing enough. There’s so many things that we can experience. And so to really be honest with ourselves about if these thoughts and feelings start to come up, these potential projections onto people, or maybe there’s some reality basis to it, but now we’re getting a little lost in it. So really, you know, knowing our clients and what they’re vulnerable to in terms of these relationship dynamics and repetition kind of things, but also really knowing ourselves and what we’re vulnerable to when we’re more likely to become controlling or abandoning or pushing the person away or wanting to pass them off to someone else or something, and all kinds of other stuff. But yeah, so I think those are two main things, just self knowledge and really trying to collaboratively with our clients, be aware of where their vulnerabilities are in the relationship, especially. But there’s other ways too that’s

Dr. Sandy Newes 42:48

interesting. When I first started again, I often reflect, I’ve been at this a long time now, and I often reflect at kind of where, what were some of the patterns that emerged in the beginning that emerged less, you know, probably in five plus years, I’ll look back and be like, oh, yeah, I used to do that thing. But, um, you know what would happen with me more often in the beginning was kind of what I now name, you know, attachment dance, where people were getting what I believed the intensity of the relationship was more than they anticipated. In the medicine, like, because I kind of get in the bubble with them, and also just the preparation. And then, you know, then some people who have that underlying, you know, dynamic would get kind of, like, suspicious, and, you know, what are you doing here? And I don’t know, you know, like, and you know, that’s a defensive response, and it’s a minute to kind of realize, like, the same defensive responses that we’re going to see play themselves out in traditional therapy, or any other relational context, it’s important that we watch for them in the medicine context as well, and not just in the medicine, but preparation, integration, medicine, yeah,

Jim Hopper, PhD 43:51

and that intensification of relationship, yeah, from the medicine and how that can open people up to vulnerability and intimacy more and then again, from like, a three hour or four hour session that’s more intimate than a 50 minute or an hour or 90 minute session. Yeah, one thing that occurred to me as you were saying that, that we experienced in the study was that, let’s say you’re working adjunctively with someone, and they feel like super connected to you, and maybe they’re healing some of their trauma in a deeper way than they were able to do in their typical, you know, 50 minute sessions for the last five years, or something like that. Then there can be this risk that now they want, oh, my God, I want you to be my therapist, and they want to get rid of their so that they can idealize us, right? Totally, it’s really, you know, hey, we may be good or even great therapists, but there can be this way that the client, through the intensity of the medicine experiences and the intimacy and the healing that can come through, that that that they may then devalue the relationship with their current therapist, and so that we can inadvertently do harm. To their alliance and their work with their primary therapist.

Dr. Sandy Newes 45:03

You just named something so important. I’m so glad you named that we actually talk about in our training program from a business side of things like, be careful, because, you know, if everybody who comes to you doesn’t that wants to leave their other therapist, then you’re going to hurt your referral networks. But I had also thought to share too, that you can then damage the therapist, you know, the client’s relationship with their primary therapist. I hope you’re okay with me, you know, continuing to pass that on into the world, because that’s really important. Oh,

Jim Hopper, PhD 45:33

sure, yeah. I mean, yeah, we had it happen. You know, someone who, at the beginning of the study said, Oh, my therapist is my rock, you know. And then they went through the process with us, and they felt like they got trauma therapy, like kind of another level. But a lot of it had to do with how much time we spent with them, the depth of experiences on MDMA. And then they fired their therapist, and then they kind of spiraled, because that was in the context of the study where we weren’t working with them ongoing. So yeah, these things can happen, and I believe that was where it really hit home for me.

Dr. Sandy Newes 46:07

So we’re almost out of time. And I had two things I wanted to ask you, so I’ll let you pick which one. Not that many people have done MDMA and cap. And so whenever I talk to somebody who has I’m always curious what they see is similarity difference, because, you know, there’s the length of time, but I think there might be something, is it the same? I actually heard you, you’re funny because you said, I don’t know if I remember saying that, but I very specifically remember you saying that ketamine can have heart opening properties when done in a heart opening relational way. And then there’s also, just like, you know, you’re in the field, you you know, sponsor a conference, like, where’s the field going? You know, what do you want to say?

Jim Hopper, PhD 46:50

Well, on the, on the ketamine versus MDMA. So I do remember saying that ketamine experiences can be very hard, opening experiences and seem just like an MDMA experience at times less reliably So, but they can the main differences, I would say, between ketamine and MDMA are not just the length and the more reliable heart opening, but ketamine is has a much greater range of doses you can use it. So at the very low doses, people can actually feel safer in their body. Even though it’s called a dissociative anesthetic, it can actually help people feel safer in their body and really do amazing embodied work and relational work. But as you go up on the dose, they can be more likely to have visions, especially if their eyes are closed, and can be more psychedelic. There can be big body and heart opening kind of thing. But then, of course, you get up at the highest doses, and with an I am, you know, intramuscular injection, for example, people can have these, you know, pure consciousness experiences that are profound spiritual experiences where they don’t have a body, they don’t, they don’t remember who they are or anything. They’re just like this light of consciousness or words don’t can, of course, capture and then they also coming back from a high dose experience, they get to see the reconstitution of themselves as an embodied narrative, interior self with stories and all that. And that can be very powerful to witness the reconstruction of one’s embodied selfhood and identity. And I’ve had clients who said that that was one of the most profound learning experiences. They from cannabis, high dose ketamine, yeah, yeah, yeah. And quickly on where the field is going. I hope it’s going to and I see signs of this. And there was a conference just in Berkeley in the Bay Area just last week of attending more to safety, to risks, to vulnerability, to the need for people to not do this outside of their competence, to do it in community, to seek support and supervision and to be really careful, especially with more complex clients who have More complex trauma, more vulnerability to reenacting trauma, not because there’s anything wrong with them, but just there. It’s a vulnerable history they have, and it’s vulnerable to be in a therapy relationship. So I’m hoping there’s going to be more and more attention to that, because there’s so much excitement and enthusiasm. But let’s scale this. Let’s roll it out fast as we can. And I think, you know, a lot of us have learned now that’s pretty dangerous, and we have to go slow and and really work in community with carefulness, competence, you know, supervision, etc. Well, some

Dr. Sandy Newes 49:31

of that’s being driven by consumers, right? They’re like, I heard this works for PTSD. You have to write everything. Let me do this,

Jim Hopper, PhD 49:37

right? Yeah? Desperation people have, and there’s so much suffering,

Dr. Sandy Newes 49:40

yeah, a lot of suffering. So, all right, well, is there any way that people can find you? I know, I assume you all are going to do the conference again next year, and that’s in February, right? So people could find you there. I don’t know if you’re, yeah, anything else that is publicly accessible? I know you’ve done some training in the past. I don’t know if you have any others coming up or I. Yeah, yeah.

Jim Hopper, PhD 50:00

So, yeah, the conference. It’s one of two Harvard Medical School conferences every year on psychedelic assisted psychotherapy. Ours is associated with the Cambridge Health Alliance. So yeah, that that happens in, you know, February or March each year. I have a website, jimhopper.com, easy way to find me if you just Google Jim Not, not the character in Stranger Things, you know, just put in psychologist or PhD or Harvard or whatever, it’ll come up. And there’s a lot of resources in there. I try to give away a lot of resources on sexual assault and child abuse, on recovered memories. And so that’s one place to find me. And I have a YouTube channel where I have some of the things we talked about today. I have like, 20 minute video talking about these kind of things at a conference. And as far as upcoming trainings for clinicians, I don’t have any other books right now, but

Dr. Sandy Newes 50:48

if they go to the website, you might find them. Yeah,

Jim Hopper, PhD 50:51

so I tend not to be a big self promoter kind of person, but yeah,

Dr. Sandy Newes 50:55

awesome. Well, thank you so much. I really appreciate your time, and I appreciate your wisdom and insights, and I really do think that you’re very good at articulating those things. So thank you for so much breath. ,

Jim Hopper, PhD 51:07

Sandy thanks for all you’re doing to educate people and and train people. And really appreciate it. Thank you.

Outro 51:17

Thanks for listening to Living Medicine. We’ll see you again next time, be sure to click Subscribe to get future episodes.