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

Many clinicians entering the field of psychedelic-assisted psychotherapy assume that the medicine alone drives healing, overlooking the critical role of the therapeutic relationship. Without a strong relational foundation, clients can experience retraumatization, disempowerment, or even harm during these vulnerable states. How can practitioners create safe, empowering, and effective therapeutic environments during psychedelic-assisted psychotherapy?

As a clinical psychologist specializing in trauma and psychedelic-assisted psychotherapy, Jim Hopper advises clinicians to combine empowerment, connection, and attunement during psychedelic therapy sessions. He advocates for trauma-informed care that supports client autonomy and competence while maintaining a genuine relational connection. Preparation, integration, and an awareness of relational dynamics like transference and countertransference are essential components of the psychedelic therapy process. By maintaining faith in the client’s inner healing wisdom, therapists can help clients feel safe, empowered, and supported throughout their healing journeys.

In this week’s episode of Living Medicine, Dr. Sandy Newes interviews Jim Hopper, PhD, Teaching Associate at Harvard Medical School, about creating safe and relational psychedelic-assisted psychotherapy sessions. Jim talks about balancing autonomy and competence, avoiding therapist overreach, and the risks of replicating trauma dynamics in therapy.

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 0:03

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 0:18

Hi everybody. It’s Sandy Newes of the Living Medicine Institute. And as I’m sure you know by now, we are a business providing resources and training and content for clinical medical providers who are interested in psychedelic assisted psychotherapy with a specific focus on ketamine assisted psychotherapy. And I am delighted today to have Jim Hopper here. So thank you so much Jim for being here. I really appreciate it. 

Jim Hopper, PhD 0:46

It’s great to be here, Sandy. Good to see you. Nice to see you too.

Dr. Sandy Newes 0:49

So I just by way of introduction, and then I’ll let Jim say a little bit more about himself. I actually met Jim, I believe, although I might have read something somewhere at a the psychedelic assisted psychotherapy Conference, which I’ll just put in a shameless plug for which is a great conference, and I just came back from there a week and a half ago. And you know, Jim, I heard you present there, and was immediately impressed by the way in which you were merging psychological theory and intervention that was recognizable from psychotherapy and clinical psych and counseling psych into the psychedelic world, and that’s something that really stood out to me, because we’ve got a lot of researcher to talk, and none of that is wrong. That’s lovely, but it was really clear to me that that you were articulating really well, kind of a grasp of the clinical process. And so, you know, been following you ever since. And we’re going to reference a talk that you gave to the wolfson’s group, the ketamine psychotherapy associates group. That was great. And so, yeah, so what else would you like to say to yourself, say to say to our listeners, to introduce yourself. 

Jim Hopper, PhD 1:58

Yeah, I’m a clinical psychologist by training. And since the I’m almost 60 now, and since the early 90s, I’ve been pretty immersed in the trauma world, some time spent with Judith Herman and being mentored by her and her organization. And I used to run Bessel van der Kolk lab for a number of years, and just being here in the Boston area, it’s kind of a mecca of trauma people, in a way. And so

Dr. Sandy Newes 2:26

trauma incubator, yeah,

Jim Hopper, PhD 2:28

so I, you know, so I’ve just been really fortunate to have great colleagues and mentors here, and to learn a lot about how to do clinical work with complex trauma. And so that’s, that’s a big part of where I’m coming from, and, and I was a therapist in the MDMA trials for PTSD the map studies. And so that was when I really started getting into the psychedelic work. I don’t do any underground work, so I was a therapist in that study. And, and I’ve been working with ketamine Since 2020 so those are, those are some things about me, and I bring different backgrounds to it. So I’ve done research, I’ve done neurobiology research, I’ve done research on memory. I’ve focused on male sexual abuse victims and their capacities for healing and what supports them. And so I’ve kind of dabbled in a bunch of different things. I could say, I guess, well, and you mentioned

Dr. Sandy Newes 3:22

a previous conversation to do some expert witness work. I don’t know if that’s kind of, you know, in those broad domains, you know, just to give it kind of a the broadest context of all about what you do in the world.

Jim Hopper, PhD 3:34

Sure. Yeah. So I do a lot of teaching for police and prosecutors around the country and around the world, and I basically, I translate neuroscience for them to help them empathize with sexual assault victims and see how they’re not so different from them, and how evolution shaped their brains to respond to to being attacked, whether that’s sexually assaulted or being shot at as a police officer soldier, and I help them Think about why people don’t fight or yell, why their memories can be fragmented. And so I translate neuroscience, and I draw these parallels between the lived experience of police and soldiers and those of sexual assault survivors to help them basically do better by survivors when they’re in the legal system. And that’s big part of what I do. And then I do. And then I do expert testimony in sexual assault cases, where I educate the jury about these things. So that’s, that’s an area where I have more influence in the world than in the psychotherapy world, but, but I love, I love both worlds, so, but that’s, yeah, that’s part of what I do as well, well.

Dr. Sandy Newes 4:35

But it’s interesting, because I think when you start to get into, you know, thinking about everything through the trauma lens, of which I, you know, share at that point, you know, we’re looking at the brain and the nervous system, and, you know, relational manifestations and how things show up in relationship. And, you know, so at that point to me, anyway, the lines between what is and is not therapy become blurry, you know, like, I mean, we’ve got, of course, the session, but. Then there’s all of the different other components of it, too. So, so, yeah, so, so here’s the million dollar question. Then, so you’re working in trauma, and then did like, you know, the MAPS thing just appear? Did you like, was that, like, the next logical step, is that, like, how did you kind of make the firm? I know many people have done it. I mean, I’m, yeah, you’re not the only one, especially in Boston, but, but you know, how did you make the leap into psychedelic assisted psychotherapy? Was it a like a mission for you? Did it just appear? Were you just interested?

Jim Hopper, PhD 5:31

Yeah. So I, as a young person, I had some psychedelic experiences in in late high school and in early college, and part of that was basically I had a vision of doing this work at some point, at age 20 and but I also had a recognition, even at that young age, that I was not he was going to take me a while. I was going to there’s a lot of work I had to do on myself to to really be in a position to to be a therapist in that role. And I also could see that the culture wasn’t ready, and might not be for a long time, so that was part of it. So I had kind of this vision of doing the work, but I knew I needed to do a lot of work on myself first. Then I had that experience with MDMA as well. There was, you know, tapping into all this love and compassion and then realizing like, wow, I’m gonna have to do a lot of work on myself to get even close to being that loving. You know, in my daily life and relationships. You know, as a 20 year old male, I had to it was some grief there, realizing like, wow, I got a lot of work to do. So then fast forward, 30 years later, I was part of a group with Bessel van de Kook and some others and and I heard, and I had been following the MAPS work even back in 98 I saw their protocol, and I could tell like, Wow, these guys really know, like, PTSD outcome research, and it sounds clinically really good. So when I heard that there was going to be a phase three trial and there was going to be a Boston site, it was like, Oh, wow, maybe it’s time, you know, right? So then I reached out to Rick Doblin, and then I became a therapist in this study. So that’s, I love

Dr. Sandy Newes 7:16

that. Oh, interesting. Yes. I was another person who heard that call and was like, I’m going to do this work at some point when the moment is right, right? The moment meaning myself, the moment meaning regulatory, the moment meaning culture, when those things line up, yeah, yeah, great. So, you know, so let’s kind of go to this trauma piece, right, like it permeates so much of what you’re talking about. And I consistently hear you talk about trauma, informed care tenants as a basis for this work, and the importance of relationship and attending to the therapeutic relationship, and, you know, solid psychotherapy principles. And I know that that might seem obvious to you, it’s just that, you know, we have a lot of people kind of entering into this field who think a lot of that the medicine, you know, is, what does the work that way, that it’s the medicine that does the healing. And what I appreciate about you, I think, you know, let you speak to it, but you know, is that it is the blending, it’s the use of the medicine. But that we’re really doing psychotherapy, and we’re really even more specifically doing trauma focused or trauma informed psychotherapy. And I just love to hear kind of, you know, what do you mean by that? You know, when you say, let’s use trauma informed care and trauma informed tenants, what does that actually mean? Yeah, so

Jim Hopper, PhD 8:37

a lot we could say about that, but there’s a couple, like fundamental principles that I think are really important. And again, Judith Herman articulated these way back in the early 90s, that good trauma treatment, as well as supporting people to seek justice, involves connecting, genuinely connecting with traumatized people and empowering them. And those two principles are just so at the heart of this work, and they’re the antithesis of what it’s like to be abused by other people, to be dominated and exploited and harmed. You know, through physical abuse, emotional abuse, sexual abuse, sexual assault. So good trauma treatment does the opposite of what a traumatizing relationship does to someone, and so those core principles of empowerment and connection are just really at the heart of it. And they’re easy to say, but they’re actually pretty profound things to try to embody in relationship with our clients. And then, you know, some other thoughts we can explore is, well, how is good trauma treatment, good psychedelic treatment? You know, we hear a lot of inner healing intelligence, and, you know, to create the conditions for someone to access their inner healing intelligence, you know, or at least increase the odds that they’ll be able to do that. That involves genuinely connecting with people, empowering them through info. Consent through really making sure that they have autonomy to make decisions about how to progress forward through the preparation phase to the medicine, what dose of the medicine, and all that. So good trauma treatment is really about supporting people to access their own inner healing capacities, and that’s at the heart of good psychedelic treatment, is to the medicine plus the relationship and the set and the setting. These are about creating conditions that can enable people to access their own healing capacities. One way I think about it, and then I also think about how we can break down the supporting of empowering people, how we can think about different dimensions of that too. So we can, we can get to that at some point, if you like, Oh, how

Dr. Sandy Newes 10:50

about now, right? I’m gonna talk about, you know, I actually just wrote it down. So empowerment and connection. So let’s talk first about the empowerment, because I really want to also kind of really separate that out and focus on the connection. It’s like, I like, you said, I mean, you said something just really important just a second ago. You’re like, Well, duh. Like, empowerment and connection, like, of course, but like, people, what does that mean? And, and it’s like, you know, doing that with skill and with intention is a lot different than just being like, I feel empowered, you know, to go out and make my own decisions. Like, it’s, yeah, you know, it’s a word that has, like, an imprecise meaning, in my opinion. So, so when you say that, like, not that we shouldn’t use it, I’m just saying, but what do you mean by empowering a client, like, and how do we do that in psychedelics?

Jim Hopper, PhD 11:34

Yeah. So one of the things that I’ve been influenced by is self determination theory by Ed DC rich Ryan, I went to University of Rochester underground undergrad. They were professors that I know so funny and in a second other conversation where it’s like a whole different thing, right? Even though I don’t do underground work, but so they talk about these three fundamental human needs of relatedness, autonomy and competence. And so when, when I think about empowering people, I think it was having these two wings to it, and one is supporting their autonomy, their their capacities and their experience of choosing freely how they want to proceed in the therapy, how they want to engage in the relationship, again, what dose they are thinking could be good for them. You know, all in consultation with me, of course, but really supporting people’s autonomy. Because, again, that’s the opposite. When someone is being abused by someone else, they’re being treated as an object to be used, and their autonomy and their needs and their will is just not something the perpetrators at all interested in. But then there’s this other aspect of empowering people, which is supporting their competence. So, you know, we talk about strengths based approaches, people’s capacities for resilience. People come to therapy with competencies. Yes, they come with, you know, limited skills, and they come with some self regulation deficits and things, but they also have their own competencies, and even some other competencies can also be limitations. So some people are highly intelligent, and it’s a competence of theirs to be able to analyze and think things through, but they can also get lost in their head, for example. So when I think of empowering people, I think about, well, how do I support their autonomy but also their competence? And as we can talk about, there’s risks, risks that if we weigh too heavily on one side or another, that we can end up actually causing harm and disempowering them and even re traumatizing them.

Dr. Sandy Newes 13:42

So say more about that if we put too much emphasis on competency and autonomy. So what I just heard that we were

Jim Hopper, PhD 13:53

too much or the other. Oh, okay,

Dr. Sandy Newes 13:54

how would that be? Re traumatizing?

Jim Hopper, PhD 13:57

Yeah, so one of the caricatures out there about the inner healing intelligence is that it’s a therapist sitting over here and the clients over there, and you’re just like, oh, just trusting your inner healing intelligence. And then the client actually may be lying down with eyes shades on, and they may be like, totally flooded with horrific trauma memories, but they’ve gotten the message from you like, wow. You know I’m supposed to be inside trust in my internal intelligence, and you can actually end up replicating abandonment dynamics that they experienced in especially in childhood. So there’s a way in which, if we’re overly confident and naively confident in the inner healing intelligence of the client, that the we can actually be too hold we can hold back too much, and they can be floundering over there, and we’re not tuned into that, because we’re so you know, rose colored glasses about enter healing intelligence, and this can definitely happen. I mean, we hear about people who’ve had this happen, who’ve had this experience. It’s something that I’ve, you know, had taste of in in the role of the client, of like you. You know, does this person really are they just do they want to deal with me? Or they’re saying, Go inside, Jim, you know, is it because the, you know, they don’t want to deal with me and I’m feeling abandoned? Or is it like, hey, that’s what I really need to be doing right now? Or whatever it might be. So I’ve experienced this, you know, in the in the role of a client, as well as witnessed it and heard my clients of these experiences now we’ve been able to catch them before they spiral out of control. But I’ve also had people who come to me, who you know, who felt like they were really neglected and abandoned in some of these relationships with with underground guides or with therapists. And I think it is something that I have heard it happening more in the underground where, you know, it’s not an ongoing therapy relationship. They might do one prep session and they don’t really know them that well, and then the person comes in, they feel totally overwhelmed and flooded. And the therapist is the guide is like, well, you know, you’ve got everything you need inside. You know, trust in the medicine, whatever, trust in your inner healing, intelligence. And people can actually experience it is profoundly abandoning and re trauma. Yeah, so I’ve heard these stories and and, but I also have just seen this dynamic, you know, I’ve experienced it and in both roles, and so it’s something I’m really sensitive to. So that’s one possibility in the in the wish to support, to support people and empower them by inner healing intelligence, then we can end up having them feeling abandoned. So that’s, that’s how that can go in an extreme direction. Then can lead to and then that can spiral, if it’s not noticed and and repaired. You

Dr. Sandy Newes 16:36

know, it’s interesting that you say that, like that people just sitting back and, you know, clients being given the impression that, like, you know, or even like people who are new to the field, or maybe those who’ve been in the field a really long time, just thinking that that means we just be with the client, like, I mean, it’s like, there’s a fundamental difference in being a sitter, you know, and holding space for somebody and getting involved, you know, in a more therapeutic way. I mean, I, and I consider that to be one of, one of the ways the intentional use of your relationship and, you know, creating, but

Jim Hopper, PhD 17:08

sometimes you think you’re holding space, and actually you come to learn later that the person felt like you had abandoned that totally, right? That’s, you know, that’s where it can go, go wrong, yeah. I mean, we’re

Dr. Sandy Newes 17:20

aware. And, you know, like for us at living Medicine Institute, like we advocate talking much of the time with the clients on ketamine. And not everybody feels that way, but that is part of that, that the client feel held, that they feel, you know, I call it getting in the bubble like that. We’re in the relationship with them, like in there with them, that it’s not just them on their own journey, and we’re just like holding space to make sure they’re okay. It’s much different than that,

Jim Hopper, PhD 17:49

more relational than that. Yeah, that can be through speaking with people, but it can also be very subtle, just how you’re attending to them and tuning into their body and the signals, and it can be intuitive. Then there’s this other side where, where I think there’s a risk of, especially from people who they have that intention and that, that concern that you do of you don’t people be all alone in there, and you want to be with them. And then one of the ways that can go is, you know, we want our clients to access certain inner strengths, or we want them to integrate certain capacities or strengthen certain competencies they might have or that might be emerging for them in terms of how they relate to their shame or to their bad memories or to whatever it might be. And so this is the the other poll that I’ve seen is that therapists can get really enthusiastic about what they have to offer this client, or they can think like, oh, I’m supporting their inner healing intelligence by making sure they get this experience of their body, or making sure they get this ADP intervention that’s gonna be so perfect Right now, or something like that. And then this can then in the zeal to make sure you’re helping them and supporting their emerging competence, that then you can end up dominating them, and they can end up feeling exploited. They can end up feeling like you’re on your healer trip, and that’s actually not what they needed. And it can feel intrusive, overwhelming. And so then the risk there is, now you’re getting into that dynamic, reenacting the ways others have dominated them and hurt them. And so

Dr. Sandy Newes 19:29

that’s part of the issue, like where we start to put, which is another thing to get to and later in this conversation, I mean, it interrupt your flow. But I think it’s part of the thing, where we’re, if we’re only doing one medicine session and viewing like that, be the end all, be all like, we’ve got to get there in this one session. Like I saw somebody today was doing a lot of developmental trauma work, and I’ve got their session with them coming up, like, at the end of this week. And so, you know, we touched into it, but I know that it’s a process. So if I were doing traditional psychotherapy, I probably wouldn’t, like, push them into that, you know, like, and I think that’s one of the dangers that we feel like everything has to happen in this medicine session, whether it be, you know, one hour on ketamine, or whether it be, you know, multiple hours on another medicine in a clinical trial, like, and I think that’s just one of the misnomers in the field that we have to do it on the medicine, yeah,

Jim Hopper, PhD 20:23

and yeah, just that sense of urgency, like, and sometimes, you know, this work can be expensive for people, like a three hour session, if they’re paying full fee there, that can be a thing that leads the therapist to really want to make sure they’re helping them. But then it can, it can go into this other territory. And I also think it’s just we all have our different styles and limitations. Like, I think for me, I’m more likely to hold back and for people to maybe feel like I’m not as in there with them as they might want sometimes, whereas I have colleagues who I think they’re more likely to go into the like, oh, gotta make sure I do this, and then people to feel like, whoa much, and not to say there’s anything wrong with us, but these are just polls that we can fall into. And we have our different personalities and our motivations and fears that can lead us to go in one direction or the other. And then if you add in the sense of like, Oh, we got to do this now or whatever, then they can exacerbate these things,

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