‍IV Ketamine-Assisted Psychotherapy | Will Ratliff of Transcend Health Solutions

When you have built something that has the ability to in general take somebody from extremely distressed and suicidal to subclinical and they'll likely maintain that over time. The fact that it's challenging to have that be believed or to even when you have hard data on it or otherwise, is very weird. Usually when you build an amazing product, it's not that hard to market and, you know, kind of put out there and so interesting how new this whole industry is and how, how we have no culture around psychedelics in America, really and that there's been so much drug disinformation and all of the things that we contend with where I come from. Something becomes standard of care when there's enough research to say that this is now the thing. You know, this antibiotic should be the one that you use for this specific condition, because we found that this one works the best. Well, if you go to uptodate the website where it says what essentially standards of care are, and you look under treatment resistant depression, the first thing listed is ketamine assisted psychotherapy. But if you ask the average clinician, you know what they think about this, they'll just have their own personal opinion and maybe I don't really refer to that or whatever. That's not the environment I come from. You do what is best and most research and standard of care, not your personal opinion.

Welcome to the Mental Health Entrepreneur Podcast. We are here to inspire creative ideas and connections for entrepreneurs and advocates working to address our mental health crisis. As you listen, I hope you will experience new ideas and motivation to innovate in your business, your community and in your life. Welcome back everyone to the Mental Health Entrepreneur Podcast. I'm your host, Rachel Harrison, and with me today to talk about an innovative approach to mental wellness is Will Ratcliffe. Will is an rn, LP and co founder of Transcend, which is an IV ketamine assisted therapy practice. Welcome, Will.

Thank you for having me on.

Yeah, so I know ketamine therapy has been in the news lately. There have definitely been a lot of things out there about this. But let's start a little bit about you. I would love to hear about your journey, so sort of how you got into this type of work.

Yeah, I think it was probably a little less typical because of my background. I started out as an EMT when I was 18, so found myself in an ambulance really early on in life. I was paramedic by 21. I spent all of my 20s just, you know, in an ambulance, in an ER critical care floor. Did work in some different areas in medicine, like drug rehab and psych and things like that. But where interesting portion of my experience was working in a helicopter. So I did medical evacuation, both as a flight paramedic and flight nurse. And so essentially where my ketamine nerd side actually was not even from mental health originally. It was for the emergency room and for critical care settings, using ketamine for that capacity for pain management, for the facilitation of passing a breathing tube and stuff like that. And so I, I knew a lot about ketamine in that capacity. And the mental health side of it was, you know, not really on my radar. But I fell into the research pretty early on that it had that use and the, I think interest, you know, coming from wanting to actually use it for more of a mental health component was just my own mental health journey. Obviously starting out in a ambulance really young. I actually was one of those folks who started to develop pretty significant PTSD symptoms really early on. Honestly just didn't know what I was experiencing. And so it took me a while to figure out that I even needed to go to therapy. Like many things were just falling apart. Couldn't exactly figure out why that was. And so through that, my own journey with all of it, I was one of those people who had tried a lot of things, had essentially found myself in a treatment resistant position, you know, where I had done a lot of therapy and still kind of felt the same way that I did. Tried traditional routes as well. And just that entire process really helped me to have a whole lot of heart for people who are in that situation, situation where they have really extensive and complex trauma as well as have tried a lot of things and are still really frustrated that things haven't budged. And so having that background was just knowing a lot about ketamine and things like that. When I saw this potential to use it for trauma therapy, I just wanted to get involved. And so the process for me was I applied to ketamine clinics and I went and I was like, I just want to go do that work. And so I saw the way that the industry looked. You know, I went to places and interviewed and saw the way that they were doing the work. And I just immediately realized, like, this is not how you do it. This is not how I would do it if, you know, I was to. To build a clinic. And so I didn't have any interest in being an entrepreneur or building a clinic or doing any of this. I honestly just wanted to be involved clinically. And so when I saw that there was no Place that I could go where it would be done ethically. I just created a place.

Ah, okay, let's dive into that a little bit. What were the things that you were seeing that you wanted to do differently?

Essentially, the psychotherapeutic support was the main thing that was lacking. A lot of places that were ketamine clinics really early on were maybe operated by a medical director that was an anesthesiologist. One of the things that is true of anesthesiologists is they really take a vow to never dabble in narcotics by any means, because they have such free access that they could easily get addicted to things very quickly if they were ever really do. So they have a culture around it. And so one of the things that was very evident is that they didn't understand exact what it's like to experience the effects of ketamine. And with that absence of knowledge, I think it's very challenging to understand how to support somebody as well as just realizing that the actual intervention is ketamine assisted psychotherapy. We're using ketamine to assist trauma therapy, therapy in general, not just administering ketamine and kind of expecting the ketamine to do all of the things which is the narrative that is so pushed out, which kind of has just stems back to big pharma and otherwise that that narrative, you can just take a really simple story, but it's just so untrue. And I wish it was true. I really wish that it was incredibly possible to just go sit in a chair and get infusion and someone's trauma dissolves away and it's never a problem for them again. But generally speaking, it's a very hard process for most people to go through that. And what I saw over and over again is that people actually have a really hard time doing that work, or even after they've done a lot of it, sometimes it doesn't feel like it has the traction or like concretes in the way that it likely. And so sometimes people have tried really hard to do good trauma therapy, but, you know, it's been very challenging either because they've been seeing providers that don't actually have a lot of experience with working with trauma, which was really oddly pervasive. I mean, which makes no sense to me. I would have thought that the average psychotherapist would be specialized in trauma, you know, but actually that's. That's not actually the case.

It is not.

I didn't know that, you know, getting involved in any of this. And so I had that situation Where I had seen therapists that were not specialized in trauma by any means. And so they were doing their best, but, you know, truthfully just didn't of the tools to help me. And the point is just lack of psychotherapeutic support. And then on the other side, just honestly, the medical side wasn't even very strong either. And so one of the issues that we realized right away when we started doing this was that if you're doing ketamine assisted psychotherapy, meaning you're doing therapy while someone's under the effects of ketamine, you have to dose very specifically to that. You can't just render somebody unconscious and then expect a therapist to be able to talk to them. And so there was a lot of need for innovation around how to do appropriate dosing for ketamine assisted psychotherapy, which all of my experience and Dr. Cord Cunningham, our medical director's experience with using ketamine for different reasons in the field, helped us to be able to know how to dose for therapy. And then having such a strong psychotherapeutic focus where every single time that we do this, we're doing it with a therapist. Patients are working with a therapist the entire way through. That's a very difficult thing to find because there usually is this kind of more myopic problem of seeing this as a brain chemical issue or the other potential issue, which is usually less problematic, that it is all trauma and that there's no other, you know, anything else to weigh into the equation. And so trying to find that balance point between these different worlds, you know, the medical and psychotherapeutic worlds, and the way that we can see an issue, but to try to be that blend or that balance between those two opposing situations, sometimes, you know, hopefully they don't oppose too much, but they oftentimes do.

Interesting. Yeah. So what have you created? What have you found that works?

Well, obviously we're a smaller entity, so we've been able to iterate and iterate and develop over time. And generally speaking, what it oftentimes looks like when someone comes for treatment first, you know, these are treatment resistant patients. You know, that's usually when we think about ketamine assisted psychotherapy. Usually when someone is, you know, they've tried the standard stuff and then they start thinking about this or the psychiatrist may refer them or otherwise. And so the first aspect of it is it's really good intaking to actually figure out what's going on. Because sometimes people come in and maybe they have a bipolar diagnosis, but they really have Complex ptsd, or maybe they have a bipolar diagnosis that isn't recognized or treated yet, or maybe they have OCD and they've never done exposure therapy for it or whatever it may be. But just getting a picture of what is going on and the degree of severity that somebody is in. And so very oftentimes that initial phase of just trying to figure out exactly why has this person not already got better yet is kind of the most fundamental. And oftentimes when someone intakes in therapy, they're kind of expecting to work with the therapist for a very long time, but we're only oftentimes going to be working with someone for like six to 10 weeks. And so we not only have to kind of rapidly figure out exactly why someone hasn't responded as well, but then also, you know, do all this treatment, really intensive therapy and kind of short succession. And so that's a big piece of it. And then when people actually come through treatment, very oftentimes when they're doing ketamine assisted psychotherapy sessions, so, you know, good intaking where they meet with their therapist that's actually trained in this modality. And then when we do sessions, we try to do the, the work that they haven't already done or the really challenging work that they haven't been able to do. That's usually the main indication is that someone actually attempts to process this and their body just shuts down. They're not able to physically. And so for those people, there can be a variety of reasons why that's the case. And of course there's many ways to increase that window of tolerance and make someone more able to do this work. This is just one of them. And it just happens to work pretty well. But the point is, is when they actually go through each session, you do therapy before, during and after. So that entire process of being very therapy heavy with the ketamine is what kind of makes the difference between our efficacy and what's kind of more common in the industry. Because ultimately ketamine will cause some transient decreases in symptoms. You know, you might experience less depression or less anxiety, but those are expected to be transient.

Okay.

And so the stuff that stands the test of time, something that somebody is still going to have with them five years from now, is usually what came out of the psychotherapy and the integration from what happens in that.

I see.

And those experiences. And so we're very focused on trying to do that work with the client as well as making the work that we do actually be permanent. And so that's the ultimate goal. I think that a lot of the industry is just kind of more focused on that immediate reprieve. And I certainly understand why clients would. Would resonate with wanting that, you know, to just feel better quickly. But ultimately, our folks, we try not to lie to them and say this may be actually a really challenging therapeutic experience. And on the other end of that, you know, once you kind of surface out of the other side, you'll likely be left with a significant less amount of burden associated with all of this, usually trauma and then the potential for really long term changes. The cool part about ketamine is it does have those actions on neuroplasticity. So sometimes even if someone has done therapy around these things, sometimes they don't see it really actually make things change in the body. And so we can see long term changes in how somebody's nervous system reacts to trauma just because we added ketamine into the mix. So that's one of the cool aspects of ketamine, is it does that. But if you just administer ketamine and launch that neuroplasticity, and it's not guided in any way, it's kind of like just drinking protein shakes and expecting to grow muscle, but you never went to the gym. You know, it's. You have to pair these things, otherwise they don't. It doesn't really go anywhere.

Yeah, yeah. I'm curious, is there research that kind of fleshes that out as well, or is that still kind of a burgeoning need in the field?

A huge need is ketamine assisted psychotherapy research.

Okay.

One of the interesting things is the earliest paper about ketamine being used for mental health purpose, all the way back to 1973 was a KP paper. It was people getting a ketamine infusion and doing therapy with a therapist under the effects of ketamine. And they called it like an abreactive agent to bring these things forth. And so the earliest conceptualization of how you might use ketamine for mental health purposes was as an accelerant to psychotherapy. And so the strangeness of this is if you kind of track it back to what happened after that with, you know, Prozac coming out and, you know, all of this sort of stuff with big pharma is there really was this different narrative eventually of chemical imbalance theory, et cetera. And so there's tons of research on mechanistic stuff with ketamine. But really quality high level research associated with KAP is sparse. There's a handful of really great studies, but it's hard to study K P because it's hard to study psychotherapy interventions in general that aren't protocolized. And K P as a modality is not necessarily something that's completely protocolized and concreted, yet it's still something that we use elements of. IFS is very heavy in ketamine assisted psychotherapy, but a lot of elements from different therapeutic modalities in KAP to be able to do that work. And so I think until K P really becomes a thing, if you will, like, this is really what this intervention is, which is going to take a lot of development, it's going to be extremely challenging to actually study it in a much more robust way. And so these head to heads between just getting ketamine and doing ketamine assisted psychotherapy. There's only just a handful of studies. And of course the data is very promising in that. But what we end up seeing anecdotally, clinically, is that it makes a huge difference. And what I'll say about how I know that is, is that when we started the clinic, we did like a lot of things that everybody else did because, you know, we were just really kind of rookies at it. And so we did offer patients to just come get a ketamine infusion, and we offered people to do ketamine assisted psychotherapy. And then we had those pools of data. And after about a year, our head psychologist, we had this meeting and he showed me the data and he was just like, it is unethical to just be giving people a ketamine infusion. Because what I can show you is that these patients don't get better in any true sense. They have temporary reductions. And then we kind of milk that along with infusions. But these patients that are doing psychotherapy as well, they're doing a treatment series, maybe they do one or two sessions throughout that next year, but they actually get better and sustain that change. And so oftentimes the major difference between just receiving a ketamine infusion and doing ketamine assisted psychotherapy is what you see in the long term, which is obviously the most challenging phase of research, you know, to actually get data on someone a year or two years after the entire process. And so those take large scale studies to be able to actually get that data where you will see the main difference between KP and just ketamine infusions or receiving ketamine in any other way.

I'm curious about people who are worried about kind of negative side effects or what could happen. What would you Say to those kind

of questions in regards to what it can be like experientially or kind of maybe a fear of a quote, bad

trip or what it's like to a bad trip or.

Yeah, the main thing is psychotherapeutic support. So unfortunately it's common to find practices that will give someone, you know, an intramuscular injection of ketamine and then walk out of the room and let them self support for us. We do an IV ketamine infusion. So if at any point the level of ketamine is a little overwhelming or just not quite right, we can adjust that real time. We can stop at any time. And with the psychotherapeutic support, if at any point somebody meets a rough patch, well, chances are that's where the real therapy work is going to be done. And so that's not necessarily a negative. When those things come up, when some trauma actually emerges, that's actually an opportunity. So we don't see that as a negative word in KP by any means. Certainly can be challenging, but we can be very careful about that exposure to that trauma because we can really titrate not only the level of ketamine that somebody is experiencing, but also they're working with a therapist where if all of a sudden the therapist realizes like, hey, this is just not productive at this point, it's just dysregulating very much like probably what you see with emdr. But to be able to have a read on this because you did a solid intake with somebody, you know kind of what their capacity is right now, we can either stop that process, we can redirect it. And so if you're well, psychotherapeutically supported and you're doing administration that allows you to be able to alter the level of experience. We just don't really have this problem, any anxiety or challenges or just anything that's happening experientially under ketamine that comes up, we can either make that productive or stop it if it's not productive. And so we don't really deal with that. But I definitely do think that that concern isn't invalid by any means. Because if somebody is, you know, they're getting a telehealth ketamine prescription to their house and they're just on their couch by themselves. Oh yeah, a lot of trauma emerges and they're in that process that can be re traumatizing. And so I don't think that that concern is invalid. I just think that the concern becomes much different when you're actually doing it correctly.

Yeah, I'm hearing that loud and clear. I appreciate that perspective. So I want to go back to this part in your story where you talked about the fact that you really never intended to open up your own practice or anything like that. You just wanted to do the thing, but you couldn't find the thing that fit for you. So now that you have done some of this, what has that entrepreneur journey been like for you?

Oh, I mean, you know, it's been hard. I've done many, many challenging things in regards to patient care. All that feels really comfortable, you know, to. To do things that are uncomfortable, and that means there's something new or. But this is an extremely challenging and highly competitive industry. And so a lot of the things. When we first started the clinic, I would go talk to psychiatrists about what we would do.

Yeah.

And, like, they would kick their office. Like, they would not want to hear, you know, what I was talking about. They thought I was crazy. They're like, so y' all are brainwashing people, and, you know, whatever it may be. And so weird ways of interpreting what we were doing. And also when I would present the data to them and being like, hey, look, you know, 83% of our patients are subclinical after a treatment series. Like, this is really, really effective, particularly in suicidality. So maybe instead of sending someone inpatient, you could send them to us if you don't really want to do that, et cetera. They. They didn't buy it. Right. Like, it just. It's. You know, I didn't learn about this in school, so it was very challenging to network with other clinicians or to. To get any kind of referral. So most of the people kind of came just from hearing about it via other means. And then in regards to, like, kind of competition, you know, when we first started, there wasn't such thing as a telehealth prescriber that would just send people ketamine to their home. It didn't exist. And so some of these things that have emerged, and then, you know, challenges with the fda, with MDMA assisted psychotherapy. So we were right in line to be one of the first MDMA assisted psychotherapy providers in the nation. And then the FDA just, you know, dropped it. And so it's like the challenges around being in a novel market have been, you know, an emotional rollercoaster, for sure. What I'm trying to say is, is that when you have built something that has the ability to, in general, take somebody from extremely distressed and suicidal to Subclinical, and they'll likely maintain that over time. The fact that it's challenging to kind of have that be believed or to even when you have hard data on it or otherwise is very weird. Usually when you build an amazing product, it's not that hard to market and, you know, kind of put out there. And so interesting how new this whole industry is and how. How we have no culture around psychedelics in America, really, and that there's been so much drug disinformation and all of the things that we contend with where I come from. Something becomes standard of care when there's enough research to say that this is now the thing. You know, this antibiotic should be the one that you use for this specific condition, because we've found that this one works the best. Well, if you go to uptodate the website where it says what essentially standards of care are, and you look under treatment resistant depression, the first thing listed is ketamine assisted psychotherapy. But if you ask the average clinician, you know, what they think about this, they'll just have their own personal opinion and maybe I don't really refer to that or whatever. That's not the environment I come from. You do what is best and most research and standard of care, not your personal opinion. There's not any room for that where I come from. But anyway, I guess my point is we still are in a phase where people are taking their personal opinion towards this versus what the hard data says about what is most effective or most indicated at a given time for a certain condition. And so very challenging landscape right now to essentially figure out how to network with other clinicians and how to do this whole thing, keep the place afloat. And then, of course, dynamic leadership. So I manage, you know, paramedics and nurses and nurse practitioners and therapists, like all of these people require extremely different management styles. You know, obviously managing a therapist who might really need a lot of emotional support, making sure that they're not getting overwhelmed or burnout with the hard work that we do versus, you know, how the management style that a nurse is used to is very different. And so I've kind of been through the boot camp of learning leadership. And when I was never planning on doing that, I was just a decent clinician myself. I didn't really have a whole lot of experience leading anybody. So now all of a sudden it's like, well, you're a leader now and so better get used to it.

Yeah. Trial by fire.

Yeah.

Wow. Are these services covered by insurance, the therapy services?

Sometimes you know, you can get reimbursement for, but every now and then we'll see someone get full reimbursement. But there isn't yet a specific CPT code for ketamine assisted psychotherapy. And even mental health indications for ketamine administration are not on label. And so it doesn't matter that there's hundreds of studies to say that it's effective. There hasn't been the millions of dollars dropped on making that actually on the label so that you can, you know, then insurances use that even though the majority of medications are prescribed off label, which is a very broken system when the majority of medications are not on label. But you know, we obviously need some change around that. But point is, the insurance companies use that as a means to say this isn't covered, you know, when it's been driven home for, you know, decades, that, you know, this is something that is useful.

Right.

There's trillion dollar industry trying to keep Kevin from, you know, basically disrupting the pharmaceutical industry. You know, this is a major threat. And so I think that there's substantial lobbying against, you know, this. And in all completely fair world it would be covered by insurance, of course, but there's, there's more to play.

I would love to maybe hear a last thought for you. If there's one thing that you could leave with someone about pursuing what you believe in or starting your own business or just about ketamine assisted psychotherapy, what would be your sort of final thought you want to leave people with?

I don't remember the exact quote, but you know, it's like the people who are crazy enough to think they can change the world, you know, tend to actually do something. Yeah, I do feel like this journey has been that way because it's like, yeah, I wasn't an entrepreneur. Like this is, you know, I had done some mental health work, but, you know, was not someone with 20 years of, you know, psychotherapy experience by any means. But I saw the need. I knew that no one else was going to fill it and I just called a place and got a lease on a thing and went to an auction and got some chairs and some paintings and you know, whatever we needed for the clinic and bought it at super low rate. We started on exposure, extremely small budget and just got rolling really small and built it from there and was scrappy about it. I guess my point is that I think there's so many ideas that will just die in the graveyard that people won't ever act on. And signing up for an entrepreneurial journey is not signing up to have everything perfect and not get punched in the chin along the way. It is just getting back up over and over and over again because it's not going to be easy, especially if you're in a novel market and doing anything really worth doing. I mean, there. It isn't an extremely profitable idea to actually help people in an extremely big way versus like kind of, you know, keeping them on some sort of trickle here. You know, when you're trying to do something that's extremely important, you're just going to face extreme challenges as well. And so you have to go into it with a mindset that like, I'm going to get punched in the chin repeatedly and every single day I'm going to come back in and try to bring that same energy to my team that, you know, we can actually continue on despite all of those challenges. And so, yes, that isn't in everybody inherently, but I do think it's something that can be built, you know, it's something that can grow through time. And so I think when I first started, I didn't feel I only had like a little flicker of that. And it's just like really grown into a flame over the years of like, it just doesn't matter, you know, like in regards to all of the challenges that we're going to face along the way. Yeah, I feel like I've become tone deaf to all of those and instead just hyper focused on the things that actually are working and the people who actually do want to talk to us and the people that we actually are helping. And so, you know, I think that's like the attitude that anybody thinking about doing anything in a big way that's really new or novel, like just all the criticism and all of the challenges and waking up and seeing that, you know, the bank account's low and I got payroll coming soon and just all of those things you have to sign up for that fun adventure. And I think that a restoration of the sense of adventure in this entire thing is something that is, I don't know, in my opinion, what life is all about. It's not an easy path, but, you know, I think just, you know, kind of tapping into that sense of adventure with all of this and not expecting it to go all easy and quitting the second that it is, but knowing that it's going to be that extreme challenge and doing it anyway, that is powerful.

Well, we will have everything about Will's company and ways to reach out and connect with him in the show notes. If you'd like to hear more. And will, I just want to thank you for being here and talking today.

Yeah, thanks for having me.