Psychodynamic Approaches To Ketamine-Assisted Psychotherapy: Dr. Erika Czerwinski

As the psychotherapy space enters a psychedelic renaissance, navigating the complex relational dynamics that emerge in altered states remains a top concern. How can therapists maintain ethical boundaries while being authentic and responsive during such vulnerable moments? What role do clinical frameworks like attachment theory and transference play when working with powerful medicines like ketamine?

According to clinical psychologist Dr. Erika Czerwinski, relational attunement, psychoanalytic listening, and ceremony-based approaches can ground and enrich ketamine-assisted psychotherapy. Distinguishing dosages helps clinicians tailor interventions based on client needs and internal states. When clients begin regaining verbal awareness during ketamine sessions, gentle, well-timed reflections can surface unconscious material, validate emerging emotional experiences, and help anchor insights for integration. By attuning to transference patterns and unconscious processes, interpretations can deepen relational safety and accelerate healing.

In this episode of Living Medicine, Dr. Sandy Newes interviews Erika Czerwinski, PsyD, Founder, Director, and Facilitator of Eleos, about integrating relational depth into psychedelic-assisted psychotherapy. Dr. Czerwinski talks about working with clients experiencing personality disorders, the difference between psychedelic and psycholytic therapy sessions, and how ketamine compares to similar psychedelics in clinical usage.

This episode is brought to you by the Living Medicine Institute.

LMI is a training, resource, and membership program educating providers about the legal and safe use of psychedelic-assisted psychotherapy.

To learn more or participate, visit https://livingmedicineinstitute.com.

Intro 00:03

Welcome to the Living Medicine podcast, where we talk about ethical medical use of psychedelic psychotherapy teaching skills, examining the issues and interviewing interesting people. Now let’s start today’s show.

Dr. Sandy Newes 00:28

Hi everyone, I am Dr. Sandra Newes and I am excited to be here with Dr. Erika Czerwinski. Erika and I actually go way back, and I’m delighted and honored that she’s choosing to be here with us and share her knowledge about clinical applications of psychedelic assisted psychotherapy, ketamine assisted psychotherapy in particular. And Erika is a licensed psychologist with extensive training in depth oriented psychotherapy, attachment theory, trauma theory and group therapy. She is certified by the Living Medicine Institute and IP in ketamine and psychedelic assisted psychotherapy, and she has been facilitating ketamine assisted psychotherapy since 2019. Prior to that, however, she has two decades of clinical practice, and she spent the last 15 years incorporating wisdom, traditions, rites of passage and ceremony, yogic philosophies, and meditation into her work.

Dr. Czerwinski maintains a private practice in Asheville, North Carolina, and she is on the board for the Western North Carolina Psychologist Association and Horizons at Carolina Day School. And Dr. Czerwinski and I go way back to wilderness therapy days, where I was wildly impressed with her clinical knowledge and that kind of a similar, in my opinion, kind of integrative approach to different types of using experience and different states and combining Psychotherapy into a more experiential oriented tradition. So I am excited again to be here. And thank you so much for joining us.

Erika Czerwinski, PsyD 02:07

Thank you. Sandy. Thank you for having me. And yeah, I think one of the reasons why I actually really love the psychedelic work and the ketamine work is because, much like wilderness, there’s a way that we get to bring different things together, and I think that it makes it really rich for me. So I like that.

Dr. Sandy Newes 02:23

Well, it’s interesting. I’ve always thought of wilderness as being kind of its own altered state work, and I’ve really begun to broaden kind of when people say, I’m into psychedelic medicine, I say it’s really about non-ordinary states of consciousness and altered states, not just the medicine itself. So and I know that’s something that you’ve also been into.

Erika Czerwinski, PsyD 02:40

Yeah. It’s how we get there. Right? It’s I mean, the same thing with rites of passage work. It’s how we can provide an environment that helps people drop into another reality in terms of their own inner world.

How could they find a place that they don’t usually get to? So that’s. Yeah, wilderness as well as psychedelic work.

Dr. Sandy Newes 02:59

Great. Thank you. So I know that you come from a particular type of tradition and as do all of us, I obviously am aware of the fact that it’s more eclectic and that you used other tools as appropriate. But if you were to describe your clinical orientation, how would you describe that kind of with an eye to how that might inform your work with ketamine?

Erika Czerwinski, PsyD 03:20

Yeah. I mean, originally I was trained in graduate school, contemporary psychoanalytic. So I really, I think, have a strong foundation of what I first start listening to material from is from that lens of depth oriented relational work. So what that means is how did this person’s experiences in relationship start to create patterns of how they relate to themselves in the world? That’s a, you know, a lot of that basic and foundation.

And then also with contemporary analytic work that brings in a lot of the attachment piece, too. So attachment lenses. How did they find safety? How did as little ones. How did we find safety and survive? 

And how did that play into the relational piece of how we respond to others to get that safety right? And so those are two parts. And then also I’d say bringing in group some of the family systems work and group work to.

Dr. Sandy Newes 04:19

When you say family systems work, how does that kind of show up for you in terms of that?

Erika Czerwinski, PsyD 04:24

Well, I think that’s that would be more with my work with couples and my work in groups. So you have more family systems work I look at in multiple in a relationship that we have multiple people in the room. How are they responding to each other and what’s the other person representing, and how do I support them in seeing their patterns of how they’re relating to others? So what’s the system that’s happening?

Dr. Sandy Newes 04:54

Well, and then so I’m wondering, I know a lot of what you’re doing and we’re going to get to that. I know that you’re doing group work and and that’s an exciting area. But in the individual work that you’re doing with psychedelic assisted psychotherapy, I’m really curious about how that that particular orientation plays itself out for you. So you mentioned, again psychodynamic and depth work, heavy relationship focus. It sounds like heavy emphasis on early relationships.

And you said what the little ones do to get their needs met and to find safety and security. And so I’m just curious how that plays itself out for you in the work that you’re doing with actual clients.

Erika Czerwinski, PsyD 05:34

I mean, I think in order to answer a question, I think we first have to distinguish between psychedelic work and psycholytic work, because that work with psychedelics, when individuals are in that deep internal state where there’s so much stimulation happening from the inside that working with. Them clinically or therapeutically on the medicine isn’t where the richness is. It’s usually having the psychedelic experience and then working that in the integration sessions. And that’s where the rich work can happen in the lower dosed sessions. So say if I’m having someone come in for ketamine and on average, if we’re starting that, you know, at a on average, people starting at that 0.5 dosage, they that’s most of the time it’s a fairly psycholytic dose, meaning it’s a lower level stimulation of having the psychedelic experience.

And so they’re really verbal. They’re able to be verbal the whole time. They’re able to maintain that there’s an outside world happening at the same time that their inside world is happening. So there is a ability to keep both places in their awareness, as opposed to the psychedelic space where you’re really taken over by that internal experience.

Dr. Sandy Newes 06:53

Okay. You mentioned just as a little aside, you mentioned that 0.5 dose range. Can you just speak to that just in case people are unaware of what that means?

Erika Czerwinski, PsyD 07:01

Sure. So when we’re doing ketamine work and all, each individual is going to respond differently to the medicine. But on the basic realm, if we’re using between the 0.5 and 0.75 MiGs per kg per kilogram of weight puts them at that average space, where that is the what research has said the sweet spot for treating depression. So we’re usually starting at that lower dosage and then seeing how someone responds and then adjusting from there. And that’s both with a ketamine induction series.

If they’re coming in for a treatment with depression where they’re doing that typical two times a week for three weeks, or if they’re coming in for a one off session or to really have it support their work with therapy or trauma. So it’s we’re not trying to do the induction for the treatment of depression, but we’re just doing using it therapeutically.

Dr. Sandy Newes 07:51

Great, thanks. So back to the question about how does that kind of more psychodynamic or psychoanalytic lens kind of play itself out in your clinical sessions? You, you know, you said, okay, well, first we have to clarify that sort of psychoanalytic versus versus psychedelic dose range. So that said, kind of I’m just really curious. Like, like if you were to say, this is what I do, that may or may not be different than others because I totally recognize, like, I don’t actually know what you do and I do this full time.

You do this full time. Like knowing that we don’t actually really always know what a session is looking like, that kind of black box of like trying to unpack that. But if you were to just speculate on that, how do you think that that lens, that theoretical lens and that view and how you conceptualize the client, how does that show up differently for you in an actual session?

Erika Czerwinski, PsyD 08:41

I think however, we work clinically without ketamine is how we’re going to start working with the ketamine. And so for me, the I think it starts with how am I attuning and listening to the material and what am I paying attention to. So I think as clinicians, we start to listen to and pay attention to different things. So how am I looking at the material and just listening to what are the themes that are coming up? Especially in a, in a psycholytic or a psychedelic session where psychedelics often they’re not speaking as much psycholytic patients will really often speak quite a lot.

So I’m listening to the themes. I’m looking at the materials through what are the feelings and the experiences coming up in the room? I think one thing that puts analytic work separates it a little bit from some other is really paying attention to the transference and working in the transference, and what that means is we’re allowing the projections of the patient to come into the room and into the relationship. And so if a patient is experiencing something, for instance, a patient might be apologizing in the session. They think that they’re not doing this right. 

I’m not doing it right. You probably think I’m doing this wrong. How do I respond to that? Or in the integration work? How do I respond to that? 

Instead of saying, wow, you were doing that, great. You were doing it right. I’m wanting to understand what that meant more. So I might try to open that up and say, you know, when you said you thought you were doing it wrong and, and I and I thought that you’re doing it wrong. Tell me more about that. 

What what what was what was I thinking at that moment? So I want to understand how they’re experiencing the projection and how do I play into that relationally. I could I could give you, I think and I could give you some examples as we go through this. But I think to get the basics down around. What are some of the things that makes that for me, how I understand analytic work is listening to the material a tuning in, working in the transference. 

I also think analytic work really pays attention to the contemporary analytic. Relational analytic will pay attention to what is the therapist’s unconscious process and what’s the patient’s unconscious process? How are we in the room together regulating in a way that we’re really experiencing one thing. And so that might be called reverie, that might be called where we’re attuning and so on. How does my thoughts start to reflect something that’s happening with the patient? 

And, you know, there is a analyst, Wilfred Bion, who would say each session we want to go in without memory or desire, because what happens in the room is what we’re going to be working with. And the use of reverie. Is that giving Right to the fact that our collective experience is creating something together. And so that’s that’s another piece of it. And and then I’d also say the use of interpretation, which is also really an interesting thing to talk about with psychedelics, because we’re really taught that we really go in and allow that patient’s experience to be its own space without interjecting anything of our own. 

And so when does interpretation come in, and how are we as analytic therapists working with that?

Dr. Sandy Newes 12:13

Well, that’s really interesting, isn’t it? Because I mean, really like that is the prevailing view. And that’s what we’re taught in training programs that we, you know, that we kind of allow and support and be with. And I, I’m really curious, like when might you use interpretation? And I get that it’s going to be variable and it’s going to change per client and all of those things like totally understand that.

But but you know, and I also I also just want to add, for my own point of view, that I think that’s the unique role of a, of a, of a therapist versus like a psychedelic integration coach or a sitter is that there might be more opportunity for that. And you know, there are pros and cons to that. And that’s kind of a controversial point of view. So I’m really curious what your thoughts are about that.

Erika Czerwinski, PsyD 12:57

And I think it’s it’s about also how do we take risks as therapists and how do we play and how do we allow ourselves to find. Give ourselves how do we bring ourselves into the room in a gentle way, where we’re not coloring somebody’s experience, but they’re not completely alone? Because I think that that’s an important thing, that anything that happens, as we know in the room is influential. That’s the whole premise of setting. Right?

So we know that by me being there, I’m already influencing that person’s journey. So if they’re having an experience and if I sit with them, it’s going to be different if I’m not sitting with them. So I know that there’s already a transferential relationship happening. And so how and at what point do I begin to use that? And I mean, I think what I try to do is in my psychoanalytic sessions and even the psychedelic sessions, let that experience happen. 

But when they’re on the tail end, when they’re really talking, when they’re quite aware they’re in the room, when they’re aware that I’m there and it’s at the tail end of the therapy, I will begin to use interpretations, and that will seed things, and that can seed relational patterns that happen in the room that then we work on in integration. So I think that giving ourselves permission to play with how we work clinically and how does that impact and look at it and see what happens in the room.

Dr. Sandy Newes 14:24

Well, that’s super interesting too, because what I heard you just say too, is that it depends on where you are in the session, that there might be some more. Is that accurate, that there might be some more room for interpretation, kind of inserting yourself a little bit more into the mix, as the person is referred to as the tale, where they’re kind of coming out and they’re coming back into their body versus when they’re kind of deeper in it. I mean, is that did I hear you correctly about that?

Erika Czerwinski, PsyD 14:49

Yeah, that’s exactly right. I think I’ve seen a lot of transfer or I’ve seen more transferential relational things come up in sessions around touch because as you know, with psychedelic work, there is a real need for touch and going over what the protocols are for touch and having the patient be able to name what’s comfortable or not comfortable, and giving permission and accessing. How do we use touch now in regular therapy we don’t use touch. And so touch becomes a really powerful exchange or relational exchange between two people, the therapist and the client in the room. And what happened in that moment is relational.

And so I am going to be working in the transference later in integration when things like around touch happen. Did I touch in the right way or did they have an experience that did happen recently where a patient who experienced themselves as. Very careful, and we’re always wanting to make sure they’re doing things right. The touch wasn’t great, and it took them a while to be able to say no. Can you change that? 

And then that became an important part of the work in integration. For them to just say, I don’t like that was a very big deal. And that was a relational exchange that happened. They were perceiving something in me that, oh my God, they’re going to get angry that I’m saying this. And so there are things that happen in the relationship in psychedelic work that become very rich material for integration, processing, that reflects patterns that have to do with patient.

Dr. Sandy Newes 16:27

Well, and it’s so interesting because for me, and I’m curious if you agree with this or not Like that intensity of that relational dynamic, and that energy like that comes up between you and the client is one something that isn’t talked about enough. I mean, we talk about it generally, but but to, you know, it can become very preoccupying for the client and for me as well. I mean, it. And so what I’m hearing you say is like taking that as being a critical part of the work.

Erika Czerwinski, PsyD 16:54

Yeah, completely.

Dr. Sandy Newes 16:55

Is that accurate?

Erika Czerwinski, PsyD 16:56

Yeah, I think it is. And that’s I mean, it’s how I work without ketamine. And so it’s going to be in ways how I work with ketamine, allowing that we’re knowing how to offer space and hold the right container for the patient, which is a safety container. But if we take ourselves completely out of the room, as if we’re just going to be the good object, that’s actually allowing them to rely on defences that need to be seen and understood. If we’re just only the good object, I know I’m not going to be the good object all the time.

Sometimes I’m going to do something wrong, so I need to be able to look at those things that actually become helpful clinical moments because they were real exchanges that happened between two people, that special and intimate.

Dr. Sandy Newes 17:39

I love that. It sounds so just authentic. Yeah. And real with what’s coming up and being really transparent with that.

Erika Czerwinski, PsyD 17:47

And yeah, we we need to I think as clinicians, we need to be able to be aware on one hand, what’s happening in the room and attuned enough to notice things and then be unafraid to say them.

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