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

Dr. Sandy Newes 18:02

Yeah. Yeah. It’s interesting. I mean, that’s one of my favorite pieces about about psychedelic work is to be able that level of authenticity and, you know, how being able to be transparent and just really in there, like with the client, is just I mean, it’s transformative for me.

Erika Czerwinski, PsyD 18:18

Yeah. And that vulnerability. Right. If we don’t have authenticity with vulnerability, then there can be something dangerous, right? Like the orphan, the patient’s very vulnerable in this state.

And so if we’re not being authentic and attuned, then they might perceive and feel something that if we’re not acknowledging that, that can be then retracted and shut down. So I think that space of being able to attune and be authentic and caring is a really important part of this work.

Dr. Sandy Newes 18:59

And I love that. And I think it, you know, it’s like, that’s what I love about this work. And it’s also just such an invitation for therapists to, hey, like, we can be real with this. The clients are super vulnerable. Can we also show up that way?

And also recognizing the importance of us doing our own work on that level so that we can.

Erika Czerwinski, PsyD 19:18

Exactly.

Dr. Sandy Newes 19:19

So so I wanted to just kind of circle back for a minute. You mentioned transference and, and just, you know, in my mind, like that’s essentially what we’re talking about here, with the authenticity and the being able to show up in a transparent way. But I also know that there can be more with that. And I’m really curious just what your thoughts are about the place for that, how that might show up for you in an actual session. You know, and what that you know how you work with that.

Erika Czerwinski, PsyD 19:49

So the question is how do I work with the transference, particularly with ketamine.

Dr. Sandy Newes 19:54

Yeah, with ketamine or you know, and yeah, in in the session and after the session, I mean, we just talked about authenticity and transparency. And to me, those are again, those are part of transference. But they’re also transference has a more specific definition in some settings. So I just want to make sure in some circles that we’re kind of talking about it in the way that you mean it.

Erika Czerwinski, PsyD 20:14

How we’re defining transference. So I see transference is the unconscious and relational experiences that someone has and beliefs, unconscious beliefs and how that gets projected outward onto a relationship. So, you know, if we look at a therapeutic relationship and you’ve been working with somebody for a while and they start to experience you in the same way that they experienced their father, and that would be the it’s the transference that they’re having to you is similar. And like they’re now relating to you like their dad. Like you’re their dad.

And that’s a transference. And so then if I accept that role and begin to understand that this is how they’re experiencing it without trying to make it go away. I then have an opportunity to work within that kind of relational pattern, to help them understand it and work through some of the experiences that have created true, good and important experiences that have created that projection, and to work with it in a in a way that helps them create more safety and create more expanded view that isn’t just a movie projector onto a screen. And that’s where more contemporary analytic work knows that my experience and who I am plays into that intersubjectivity. It’s not just the patient’s experience, it’s mine too, so that we’re looking at it from an intersubjective lens.

Dr. Sandy Newes 21:44

I mean, what comes up for me when you say that is relationship safety? And I’m curious, you know, like, like a lot of people come in and that I work with that are very fearful of relationships, whether it be, you know, grounded in parental relationships or other important relationships. And I’m just kind of curious if you see that as well and what your thoughts are, if you can use the transference to create safety, or how do you see that playing itself out?

Erika Czerwinski, PsyD 22:08

Well, I think in ketamine work because we’re not working always in very long term ways. You know, on average say I’m doing five prep sessions, which allows me to know their history, allows of both their relational history as well as their psychedelic history, and think about what elements they’re really coming up for them that they want to work on. So I’m not this isn’t long term work for the most part. I do have some of my patients that are long term that do do ketamine work, and that is a richer experience because there’s more relational history between the two of us, and I know them a lot better. But if it’s someone coming in to work on something, particularly with ketamine and that, and then they’re going to go back to their other therapist, then I’m not necessarily working in the transference as a relational transference, but it might be an enactment or something that happens in the room that they believe they have a perception of me that then we get to work with.

So it might be a smaller chunk of something that happens, a momentary experience that gets projected outward. For instance, I had another patient who really struggled with a lot of shame and had a history of childhood sexual abuse, and they had a very big feeling come up for them in the session, and I was encouraging them to stay with it. They really wanted to vacate and be like, I don’t want to do this. I don’t want to feel it. And as you know, in psychedelic work, we ask them in a gentle way, can you, can you stay with that? 

Can you lean into that? So when they were having a big feeling and were encouraging them to stay with it, they did. And I had this flash as the feeling is very big for them. And they had such an overwhelming experience of shame. I had a flash of this person being really young and my connection was to sexual abuse. 

And so this is a place where I’m allowing my reverie to inform what I’m thinking. Now, I don’t know if I’m right or not, but I then as they were sharing that how how small they felt and how big the shame was and how hard it was for them to be seen. And so I had said something like, what’s it like if you feel that feeling and know that I’m still here with you. And so that they were feeling the feeling while someone else is there. And that’s both really challenging but also somewhat comforting. 

It’s a it’s a both. And they were able to stay with that feeling and shared more about it where it was in their body. What was the experience, what was the belief that they were having. And I then took a risk, and I did say something about wondering about this feeling and being small. And so I was using my reverie and I did. 

And this also, I will say this was at the very, very end. So they were very verbal. Again, we talked about that tail end of being in the ketamine session. So I used an interpretation and they said yes. Right now my mind has a memory of. 

And then they started sharing a memory from when they were small. And so that was this collaborative work that was co-created from what I was experiencing with them and giving them space. But I’m still offering something. And so I think that’s an example of, in these lower psycholytic levels, how the therapy was happening in the room without it just being them alone in their experience.

Dr. Sandy Newes 26:01

I love that that sounds really, really powerful. Just giving the client such a different felt sense of experience, of being in relationship with you during such a such a time where we have the opportunity to make such profound change. James.

Erika Czerwinski, PsyD 26:15

Yeah. And then having that space. The amazing thing with ketamine too, is that then you see each other the next day when they’re not in an altered state, but still really remembering that experience, and they come back and speak about things. And I do think with psychedelics in general, it’s evocative. Right.

It either and ketamine specifically, I have a lot of my patients that connect to memories that they have, but they haven’t delved into in a long time. It feels a little safer, or it feels more alive in their body to reconnect to those experiences.

Dr. Sandy Newes 26:50

I love that. One thing I think that you and I really share, as I hear you talking, is just this importance on on the relationship and how important that experience of the relationship, not just having the relationship, but the experience of the relationship is so. And that leads me to another question that I wanted to ask you is in what way, if at all, do you see attachment issues showing up for clients in this space.

Erika Czerwinski, PsyD 27:20

When I think about attachment issues and how someone relates, are they more avoidant? Are they more reaching out for connection? I, I mean, I actually think I look more at the fine tuned relational patterns. I do think that attachment patterns and ways of relating will come up. I think I get a little more nuanced with the flavor of certain feelings.

If it’s feelings of unworthiness or not wanting to be seen which play into attachment patterns. But I think I go a little bit more granular than that. If we had a broad scope look at attachment patterns, and I do a lot of attachment work in my couples work with ketamine. I think I work more granularly in that.

Dr. Sandy Newes 28:18

Right. So one of the things that we didn’t, I didn’t ask you in the beginning was just just if you want to just give a really brief introduction to kind of, you know, the populations that you work with and different routes of administration and, and just kind of how that might work itself out for the population that you work with.

Erika Czerwinski, PsyD 28:37

Sure. I think I work with three main populations. So in my individual private practice, I see patients that are fairly high functioning and can I guess I’ll say they’re of that normative set in my also do work with a residential young adults program, and those individuals come in with high levels of depression, anxiety, OCD, a mix of. Areas that would need working on. And many of them come in having had lots of treatment before.

That hasn’t helped. And so I work with them with ketamine mainly, I think, to work on some of the deep depression, suicidality, intense trauma or anxiety. So that’s a different subset. And there are also mixed with personality disorders. And and then I also do group work ketamine group work which is totally separate as well.

Dr. Sandy Newes 29:40

Great. So you mentioned personality disorders and that that, you know, in my experience, that’s been kind of a very controversial area that, oh, psychedelic assisted psychotherapy or ketamine in specific not good for personality disorders. And yet as we move more and more into higher levels of clinical sophistication and it becomes more awareness in the mainstream and people come in for a wider range of issues. I mean, it’s likely that we’re going to see more and more of that. And you mentioned specifically that you work with it.

So I’m curious what your thoughts are about that.

Erika Czerwinski, PsyD 30:11

Yeah, I would say I don’t work with ketamine to treat the personality disorder, but I work with the ketamine. If there’s multiple layers that this person’s coming in with and if they’re struggling with suicidality or, you know, have a treatment as they’ve called treatment resistant depression or depression that hasn’t really been able to be met or alleviated, I’m not going to not see them because they have a personality disorder. And so what I’ve noticed in individuals that struggle or that have depression, as well as a personality disorder, that the depression, as the depression starts going down and they’re starting to feel more active and better, the personality disorder traits will come up. So that’s I mean, one of the the noticing, the one of the things that I’ve noticed. But at that and then it allows their home treatment, the, the program that they’re in to work more heavily on the personality disorder because their depression is not weighing them down so much.

And so that’s been an interesting like segue. Like start alleviate the depression and then work with the personality disorder more deeply.

Dr. Sandy Newes 31:22

That’s so interesting that you say that, because one of the things that I noticed for me, and I’m curious if that is the same for you, which is actually one of the reasons I asked about attachment, is that clients that I work with who have personality traits or kind of underlying personality patterns, what I witness is that they might start to do more of a push pull in the relationship, and they might see that, oh, maybe I want to do some some sessions by myself, or I’m not sure if I want to keep doing this. And in the beginning I was like, oh, maybe I’m not doing this well. Now I see that more as a as an attachment dance or, you know, which can be related to personality disorder traits. And I’m just curious if that is similar for you.

Erika Czerwinski, PsyD 32:02

I like the distinguish. I like that you’re adding in the foundation of attachment for what we have called personality disorders, because they do not what you do not have a personality disorder without attachment disruption. So I really like that you’re naming that. And I have seen again, this is where if you have a patient that’s saying, oh, I think I’m going to do it alone this week. Whoa.

What a great opportunity to go into that relational work with them. And I have had that happen. I have had individuals who struggle more with personality traits that it will come up in the middle of the treatment because they’re activated. And then how do you work with that in a regular session that they’re not on medicine? So I do think you can take the experience that comes out of what happens. 

What’s the transaction that happens in the psychedelic work? Oh, I’m not going to I don’t want you there today. Well, then it’s not just to me. It’s not just well, okay, fine. Don’t have me there, I might say. 

Yeah, okay, let’s try this one without. But then I’m definitely going to come back and talk about that thing. What is it now in the relationship between us that’s coming up? And so that’s really rich material. So it can be an instigator. 

Bring the material into the room.

Dr. Sandy Newes 33:14

Well and it’s interesting because it’s so easy to say okay. Well you know, I don’t know for me they.

Dr. Sandy Newes: 33:19

Don’t want me or I don’t know.

Dr. Sandy Newes 33:20

You know, it’s almost like it’s it’s an interest. I mean, I agree with you. It’s just really rich. And it’s also really great learning for me to kind of notice my relational dynamics with the client as well. Yes.

So great. Well, so I wanted to just switch gears a little bit, you know, with the psychedelic renaissance on its way or in full swing, kind of depending on what your point of view with this is. And, you know, there’s a lot of discussion about differentiating different medicines. Do we or don’t we need different medicines and what are the benefits of the different medicines. And I’m really curious what your thoughts are about that. 

You know, do we need to do that. And obviously this is a really broad discussion and could be kind of a whole discussion in and of itself. But, you know, why would we use ketamine versus something else? Obviously, ketamine is legal right now, so let’s just own that. Like ketamine is the only thing that’s legal. 

And while there’s opportunities in the underground, that’s not what we’re talking about here. So so to me that’s a very basic one. But beyond that, assuming that, you know, other things come on the horizon. MDMA is likely going to be legalized soon for therapeutic use within 2024. What are your thoughts? 

Where does ketamine fit in that?

Erika Czerwinski, PsyD 34:31

I love this question because I think we’re going to have so much more opportunity when other medicines become legal to really have this differentiation of, oh, what is this? What does this person need? You know what’s going to be most suited for what they’re coming in with? And also chemistry is like, I know my body chemistry does not metabolize amphetamines really well. So it’s really intense for me to be on MDMA because I don’t break down amphetamines that well.

So each person has the biological part. And then what’s the clinical part that they’re needing? I mean, ketamine, what I’ve seen and what I love is that, yes, we know it’s a really, really good for depression. I also see it helping the subjective space that the objective observer in a way that have a little bit more distancing from some of the inner experience that they have. And also because it’s such a kinesthetic medicine, I think it’s more kinesthetic than some of the others that you’re really people will really feel they’re on a roller coaster or they’re moving, they’re spiraling. 

And that brings up body sensation. So it brings people into their body. And I also find, I don’t know if you found this, that a lot of my patients will have it is instigates memories like it’ll it’ll trigger up memories from the past they haven’t thought about. So I think when I’m looking at, okay, if we used to call a differential diagnosis like differential assessment of what medicine should you go on? I love the work that’s happening with MDMA and trauma. 

I trauma. I mean, that is such a graceful, holding, gentle, conscious way of doing trauma work. And I also know that we don’t have that available to us. So I’m doing trauma work with ketamine, and it’s working right. I mean, people are really coming into the body. 

So I, I particularly love ketamine also because it’s so short acting and that we can have a two hour session and that two days later we can have a two hour session, it’s less intense on the body than some of the other medicines, and so it allows to have more repetitive uses to go in, as opposed to, I think, some of the other medicines that. Do better at maybe a one off. Like I think psilocybin does a lot with the one off. And these are just my personal this is not scientific. This is my personal assessment of it. 

So am I answering that question?

Dr. Sandy Newes 36:48

No, I just think it’s really interesting. I mean, I’m just going to zero in on what you said about, like, the trauma thing, just because it kind of cracked me up, like the prevailing view in the field and, you know, even just a couple years ago, and in a lot of circles now is that we don’t use ketamine for trauma. But I think that to me, that’s the really significant differentiating piece, one of them with ketamine assisted psychotherapy versus ketamine treatment alone, where somebody’s just doing kind of the more pharmaceutical and they don’t have a therapist, is that, you know, you and I both have an extensive background in working with trauma. And when I have clients that come in with trauma, we’re going to do trauma work.

Erika Czerwinski, PsyD 37:22

Yeah.

Dr. Sandy Newes 37:22

But I don’t think it like, naturally happens that like.

Erika Czerwinski, PsyD 37:26

When we have depression, we don’t have depression without trauma usually.

Dr. Sandy Newes 37:30

Right, exactly.

Erika Czerwinski, PsyD 37:31

The trauma is always kind of there in every human, just at different levels. So I think we go with where the medicine brings the patient, like wherever it goes, we are there with them. And sometimes that’s a lot of times it has to go in with those deeper pains of trauma.

Dr. Sandy Newes 37:50

I love that. So two more questions that I want to ask you. Now, I know that you also run cap ketamine assisted psychotherapy groups. So that’s super exciting. Really cutting edge.

And I’m just curious, you know, if you could just tell us a little bit about that. And then how is that different than individual.

Erika Czerwinski, PsyD 38:07

Yeah. Well one I, I love the opportunity, given my experience with rites of passage work and some wisdom traditions that I get to. I think for me, it’s like I get the excuse of actually bringing in more of this ceremonial piece and the sacred work, which I don’t get to do in the same way in the office. You know, this is my office, so it’s pretty a normal therapy office. But when we get to have a group on a retreat land or a separate space, I get to bring that frequency of consciousness in.

And so what is it like to hold a type of consciousness for a group that everybody drops into that level of consciousness together? And then the cool thing about ketamine and Group is that it’s amazing how one person will be talking about what came up for them and their journey. And then someone across the room is like, oh, wow, You. You’re speaking for me. Like this is what’s happening. 

So there’s this interesting connectivity that happens in groups. And people, I think, then have this experience of feeling seen and being vulnerable together and having a very vulnerable experience. Going under a psychedelic together in a very safe container is often a very profound experience. And it’s also more inexpensive. So that’s a that’s an asset too.

Dr. Sandy Newes 39:20

I love that it definitely is more cost effective. And I think that we’re going to see more and more of it. And I just want to speak to, you know, I’ll talk to clients and they’re like, oh my God.

Dr. Sandy Newes 39:28

I couldn’t possibly do that.

Dr. Sandy Newes 39:29

In a group. And in a way, for me, that’s almost the reason to do the group and also speaks to how important it is that we have a, you know, trained and skilled facilitator who knows how to manage, you know, the dynamics with that because it is a vulnerable state.

Erika Czerwinski, PsyD 39:43

Yes. And to be able to hold that both the combination what I love about it, just how it fits for me is who I am as an individual is I get to both use my clinical skills of navigating and facilitating group with this other precious part of my life, which is more of the sacred and the spiritual work of being connected to things in these larger realms, of being connected to the earth, being in nature, being present to the larger unseeable realms.

Dr. Sandy Newes 40:12

I love that. So that brings me to my last question. So what about ceremony? Obviously you just said this is a very precious to you, which I appreciate that word. Part of your work and just, you know, how do you bring that in?

Erika Czerwinski, PsyD 40:26

Well, there’s two I guess I’m thinking of two parts. One is how I bring it in the room with my individuals and in individual work. I spend a good amount of time. I think it’s so important for us to do really, really solid prep work. And for many people, that might be 1 or 2 sessions.

But I really think on average, if someone’s new to me, it’s going to be a minimum of five sessions and that Allows us to get distilled down to what’s really important, what’s sacred to them, what is their how to what is their way of connecting to themselves, and how do we bring a few of those elements into the room to make this special? This is a special thing that we’re doing. And I will say that I will really say this is special. What we’re about to embark on, this is an opportunity for us to reach places that maybe you haven’t reached before, but you’re you’re spending a lot of money and you’re putting a lot of energy into this. So how could we make this really sacred, what’s sacred for you? 

And so I’ll really try to dial into that particular individuals way. And that might be maybe we they bring a photo of something, or maybe they bring a totem that’s saying, hey, we’re marking this as a bargaining session. Now, we’re doing that in a doctor’s office. So first the doctor will come in. I work with Ivy mainly, and they’ll come in and they’ll do their medical things, and then it’s okay. 

Now we can start. So I let the medical stuff be in the front part, and then we’re setting up our space and starting. So that’s individual. And then in the groups, that’s where I really love bringing in the sacred parts, because when people, as soon as they walk into the space, there is an energetic field. And that’s kind of sounds woo woo. 

But there’s a way that we’re creating a space that they can feel. And that might be how have we prepared the room? How have we started? Are we what threshold are they crossing to know? Literally a doorway. 

We are now in a sacred space. And how do we create that? By by. Are they bringing an altar item and how are we creating altars together? So bringing that element of ceremony or intention I think intention really goes along with ceremony into the group work is makes it for me exciting and powerful.

Dr. Sandy Newes 42:43

And I think it gives such, it gives such a wonderful anchor point to, you know, it’s a very tangible, experiential piece that I think, especially for me, which people have had so much therapy to, to also kind of be able to weave in together that, you know, solid clinical lens that you so obviously have with this anchoring within the ceremony and the experiential components of that, whether it be a felt sense or a sacred object or even just a visual, something that’s really different, kind of, like you said, connecting them to those larger realms, I love that.

Erika Czerwinski, PsyD 43:16

Yeah. And I think this is something that, I mean, the psychedelic renaissance, in a way, in the world right now is bringing to us. Really, why are we doing it? To expand our consciousness, to get to places that we may not be able to get to. And yet, do we always need psychedelics to get there?

No. We can do this, as I know. You know, because you’re also in the field of wilderness therapy where we never use psychedelics, but they get to these other deeper places. And so I think humans right now are needing ways to touch into deeper places within themselves, and psychedelic containers are one way of doing that. Not all the ways. 

But if I can couple that with some of these other modalities, then it’s great. More powerful.

Dr. Sandy Newes 43:56

Well, and what I hear there is building bridges, like building bridges from other non-ordinary states of consciousness or other ways of connecting to yourself on a deeper level, or bridging the psychedelic experience or the ceremony, and just to kind of continue to build bridges into consciousness expansion far beyond psychedelic work. So great. So I’m just wondering, is there anything else that you want to say before we close? Anything that kind of is up for you or that we didn’t cover that you want to add in?

Erika Czerwinski, PsyD 44:29

I think I would I would want people who are watching them. These are mainly clinicians. And I think what I would want to encourage people to do is first to have enough of their own experiences with the medicine, which I know living medicine, you guys do really well. I think you do an excellent job of that, and then also to be in consultation groups to really bring your case notes in private, confidential case notes that get shared with other clinicians so that we can see what everybody’s doing and learn from it. And to have a container where you feel safe enough to experience your own style.

Like, who are you? That who do you bring into the room, and how do you develop that part of yourself to be more comfortable and and getting trained and. Yeah, and the last thing I’ll say is that I, I’m continuing to do groups. So if people are interested they could find me to do groups.

Dr. Sandy Newes 45:22

Great. I’m sure that you do an amazing job with that. And it would be a real privilege for anybody to participate in that. So. So, Erika, I just wanted to give you my heartfelt thanks.

Thank you so much for coming to this and to sharing in this experience with me and sharing with all of us your wisdom and your knowledge and and just speaking so beautifully and eloquently about this. I think you do an amazing job of linking together and the experiential component and that clinical and assessment piece. So thank you so much for for that.

Erika Czerwinski, PsyD 45:53

Thank you. Thank you for inviting me. And yeah, I am very grateful for the work that you’re doing to bring awareness and the clinical acumen to this work and to be out there doing all the good work you guys are doing at Living Medicine.

Dr. Sandy Newes 46:08

So great. Well, thank you so much. We appreciate you. Bye bye.

Outro 46:23

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