Latest / The Mental Health Evolution / Ep 57: IV Ketamine-Assisted Psychotherapy with Will Ratliff

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Ep 57: IV Ketamine-Assisted Psychotherapy with Will Ratliff · The Mental Health Evolution

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  (Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick Podcast Network.
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  Learn more at listenfrederick.com.
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  Welcome to Mental Health Evolution, a podcast about what's changing in mental health and
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  why it matters.
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  I'm your host, Rachel Harrison, inviting you into honest conversations with people from
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  all perspectives in the field, clinicians, tech founders, investors, insurance companies,
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  and all the folks in between.
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  Let's explore what's working, what's not, and what's next.
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  Welcome back, everyone, to the Mental Health Evolution podcast.
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  I'm your host, Rachel Harrison.
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  I wanted to give you a little bit of context for this episode.
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  Last week, we had a really great conversation with Miriam Barthes, co-founder and CEO of Journey
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  Clinical and about the business and systems side of ketamine-assisted psychotherapy, how
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  a therapist actually accesses this treatment, learns how to do it, what the regulatory
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  landscape looks like, how to bill for it, and where psychedelic medicine is heading.
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  So this week, I wanted to follow up with that with something a little bit different.
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  We are diving into our archives to bring up a conversation I recorded on my previous podcast,
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  The Mental Health Entrepreneur, with Will Ratliff, co-founder of Transcend Health Solutions,
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  one of the world's leading ketamine-assisted psychotherapy practices.
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  Where last week's conversation really focused on the business, legal, and insurance side
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  of psychedelic-assisted therapy, this one goes into what that therapy actually looks like.
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  Will is a paramedic and registered nurse who spent over a decade focused on physical trauma
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  before pivoting to psychological trauma.
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  He shares how his background led him to ketamine therapy, what a session actually looks like
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  medically, the importance of psychotherapeutic support alongside the medicine, and his own
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  journey with PTSD that led him to found Transcend.
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  After the conversation aired last week about the nuts and bolts, we had a lot of requests
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  for talking about what does this therapy actually look like.
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  So we wanted to pull this from the archive today.
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  I know you're going to enjoy the insights from Will, and without further ado, we'll
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  have you dive into this episode.
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  Welcome back, everyone, to the Mental Health Evolution podcast.
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  I'm Rachel Harrison, and with me today to talk about an innovative approach to mental
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  wellness is Will Ratliff.
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  Will is an RNLP and co-founder of Transcend, which is an IV ketamine-assisted therapy practice.
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  Welcome Will.
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  Thank you for having me on.
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  Yeah.
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  So I know ketamine therapy has been in the news lately.
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  There have definitely been a lot of things out there about this, but let's start a little
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  bit about you.
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  I would love to hear about your journey, sort of how you got into this type of work.
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  Yeah, I think it was probably a little less typical because of my background.
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  I started out as an EMT when I was 18, so found myself in an ambulance really early
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  on in life.
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  I was paramedic by 21.
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  I spent all my 20s just, you know, in an ambulance, in an ER, critical care floor.
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  Did work in some different areas in medicine, like drug rehab and psych and things like
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  that.
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  But where an interesting portion of my experience was working in a helicopter.
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  So I did medical evacuation, both as a flight paramedic and flight nurse.
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  And so essentially where my ketamine nerd side actually was not even from mental health originally,
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  it was for the emergency room and for critical care settings using ketamine for that capacity,
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  for pain management, for the facilitation of passing a breathing tube and stuff like
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  that.
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  And so I knew a lot about ketamine in that capacity.
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  And the mental health side of it was, you know, not really on my radar, but I fell into
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  the research pretty early on that it had that use.
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  And the, I think, interest, you know, coming from wanting to actually use it for more of
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  a mental health component was just my own mental health journey.
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  Obviously starting out in an ambulance really young, I actually was one of those folks who
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  started to develop pretty significant PTSD symptoms really early on, honestly just didn't
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  know what I was experiencing.
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  And so it took me a while to figure out that I even needed to go to therapy.
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  Like many things were just falling apart, couldn't exactly figure out why that was.
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  So through that, my own journey with all of it, I was one of those people who had tried
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  a lot of things, had essentially found myself in a treatment resistant position, you know,
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  where I'd done a lot of therapy and still kind of felt the same way that I did, tried
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  traditional routes as well.
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  And just that entire process really helped me to have a whole lot of heart for people
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  who are in that situation where they had really extensive and complex trauma as well as have
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  tried a lot of things and are still really frustrated that things haven't budged.
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  And so having that background was just knowing a lot about ketamine and things like that.
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  When I saw this potential to use it for trauma therapy, I just wanted to get involved.
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  And so the process for me was I applied to ketamine clinics and I went and I was like,
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  I just want to go do that work.
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  And so I saw the way that the industry looked, you know, I went to places and interviewed
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  and saw the way that they were doing the work.
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  And I just immediately realized, like, this is not how you do it.
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  This is not how I would do it if I was to build a clinic.
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  And so I didn't have any interest in being an entrepreneur or building a clinic or doing
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  any of this.
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  I honestly just wanted to be involved clinically.
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  And so when I saw that there was no place that I could go where it would be done ethically,
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  I just created a place.
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  Ah, OK.
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  Let's dive into that a little bit.
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  What were the things that you were seeing that you wanted to do differently?
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  Essentially the psychotherapeutic support was the main thing that was lacking.
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  A lot of places that were ketamine clinics really early on were, you know, maybe operated
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  by a medical director that was like an anesthesiologist.
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  One of the things that is true of anesthesiologists is they really take a vow to never dabble
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  in narcotics by any means because they have such free access that they could easily get
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  addicted to things very quickly if they were ever really do.
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  So they have a culture around it.
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  And so one of the things that was very evident is that they didn't understand exactly what
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  it's like to experience the effects of ketamine.
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  And with that absence of knowledge, I think it's very challenging to understand how to
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  support somebody, as well as just realizing that the actual intervention is ketamine
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  assisted psychotherapy.
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  We're using ketamine to assist trauma therapy, therapy in general, not just administering
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  ketamine and kind of expecting the ketamine to do all of the things, which is the narrative
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  that is so pushed out, which kind of has just stems back to Big Pharma.
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  Otherwise, that narrative, you can just take a really simple story, but it's just so untrue.
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  And I wish it was true.
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  I really wish that it was incredibly possible to just go sit in a chair and get infusion
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  as soon as trauma dissolves away.
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  It's never a problem for them again.
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  But generally speaking, it's a very hard process for most people to go through that.
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  And what I saw over and over again is that people actually have a really hard time doing
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  that work. Or even after they've done a lot of it, sometimes it doesn't feel like it has
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  the traction or like concretes in the way that it likely should.
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  And so sometimes people have tried really hard to do good trauma therapy.
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  But, you know, it's been very challenging, either because they've been seeing providers
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  that don't actually have a lot of experience with working with trauma, which was really
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  oddly pervasive.
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  I mean, which makes no sense to me.
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  I would have thought that the average psychotherapist would be specialized in trauma,
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  you know, but actually that's that's not actually the case.
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  It is not.
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  I didn't know that, you know, getting involved in any of this.
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  And so I had that situation where I had seen therapists that were not specialized in
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  trauma by any means.
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  And so they were doing their best.
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  But, you know, truthfully, just didn't have the tools to help me.
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  And the point is, is just lack of psychotherapeutic support.
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  And then on the other side, just honestly, the medical side wasn't even very strong
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  either. And so one of the issues that we realized right away when we started doing this
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  was that if you're doing ketamine assisted psychotherapy, meaning you're doing therapy
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  while someone's under the effects of ketamine, you have to dose very specifically to
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  that. You can't just render somebody unconscious and then expect a therapist to be able to
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  talk to them. And so there was a lot of need for innovation around how to do appropriate
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  dosing for ketamine assisted psychotherapy, which all of my experience and Dr.
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  Corkerham, our medical director's experience with using ketamine for different reasons in
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  the field helped us to be able to know how to dose for therapy and then having such a
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  strong psychotherapeutic focus where every single time that we do this, we're doing it
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  with a therapist. Patients are working with therapists the entire way through.
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  That's a very difficult thing to find because there usually is this kind of more myopic
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  problem of seeing this as a brain chemical issue or the other potential issue, which
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  is usually less problematic or that it is all trauma and that there's no other, you
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  know, anything else to weigh into the equation.
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  And so trying to find that balance point between these different worlds, you know, the
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  medical and psychotherapeutic worlds and the way that we can see an issue.
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  But to try to be that blend or that balance between those two opposing situations,
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  sometimes, you know, hopefully they don't oppose too much, but they oftentimes do.
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  Interesting. Yeah.
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  So what have you created?
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  What have you found that works?
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  Well, obviously, we're a smaller entity, so we've been able to iterate and iterate and
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  develop over time and generally speaking, what it oftentimes looks like when someone
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  comes for treatment.
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  First, you know, these are treatment resistant patients.
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  You know, that's usually when we think about ketamine assisted psychotherapy, usually
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  when someone, you know, they tried the standard stuff and then they started thinking
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  about this or the psychiatrist might refer them or otherwise.
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  And so the first aspect of it is it's really good in taking to actually figure out what's
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  going on, because sometimes people come in and maybe they have a bipolar diagnosis, but
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  they really have complex PTSD or maybe they have a bipolar diagnosis that isn't been
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  recognized or treated yet.
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  Or maybe they have OCD and they've never done exposure therapy for it or whatever it
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  may be. But just getting a picture of what is going on and the degree of severity that
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  somebody is in.
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  And so very oftentimes that initial phase of just trying to figure out exactly why has
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  this person not already got better yet is kind of the most fundamental.
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  And oftentimes when someone intakes in therapy, they're kind of expecting to work with a
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  therapist for a very long time.
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  But we're only oftentimes going to be working with someone for like six to ten weeks.
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  And so we not only have to kind of rapidly figure out exactly why someone hasn't
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  responded well, but then also do all this treatment, really intensive therapy and kind of
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  shorts the session. And so that's a big piece of it.
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  And then when people actually come through treatment, very oftentimes when they're doing
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  ketamine assisted psychotherapy sessions, so, you know, good intaking where they meet
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  with their therapist that's actually trained in this modality.
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  And then when we do sessions, we try to do the work that they haven't already done or
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  the really challenging work that they haven't been able to do.
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  That's usually the main indication is that someone actually attempts to process this and
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  their body just shuts down.
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  They're not able to physically.
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  And so for those people, there can be a variety of reasons why that's the case.
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  And of course, there's many ways to increase that window of tolerance and make someone
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  more able to do this work.
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  This is just one of them.
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  And it just happens to work pretty well.
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  But the point is, is when they actually go through each session, use therapy before,
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  during and after.
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  So that entire process of being very therapy heavy with the ketamine is what kind of makes
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  the difference between our efficacy and what's kind of more common in the industry.
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  Because ultimately, ketamine will cause some transient decreases in symptoms.
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  You might experience less depression or less anxiety, but those are expected to be transient.
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  And so the stuff that stands the test of time, something that somebody is still going to
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  have within five years from now, is usually what came out of the psychotherapy and the
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  integration from what happens in those experiences.
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  And so we're very focused on trying to do that work with the client, as well as making
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  the work that we do actually be permanent.
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  And so that's the ultimate goal.
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  I think that a lot of the industry is just kind of more focused on that immediate reprieve.
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  And I certainly understand why clients would resonate with wanting that, you know, to just
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  feel better quickly.
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  But ultimately, our folks, we try not to lie to them and say this may be actually a really
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  challenging therapeutic experience.
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  And on the other end of that, you know, once you kind of surface out of the other side,
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  you'll likely be left with a significant less amount of burden associated with all of
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  this, usually trauma, and then the potential for really long term changes.
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  The cool part about ketamine is it does have those actions on neuroplasticity.
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  So sometimes even if someone has done therapy around these things, sometimes they don't
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  see it really actually make things change in the body.
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  And so we can see long term changes in how somebody's nervous system reacts to trauma
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  just because we added ketamine into the mix.
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  So that's one of the cool aspects of ketamine is it does that.
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  But if you just administer ketamine and launch that neuroplasticity, it's not guided in
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  any way. It's kind of like just drinking protein shakes and expecting to grow muscle.
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  But you never went to the gym.
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  You know, it's you have to pair these things.
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  Otherwise, they don't it doesn't really go anywhere.
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  Yeah. Yeah.
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  I'm curious, is there research that kind of fleshes that out as well, or is that still
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  kind of a burgeoning need in the field?
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  A huge need is ketamine assisted psychotherapy research.
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  One of the interesting things is the earliest paper about ketamine being used for mental
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  health purpose all the way back to 1973 was a KAP paper.
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  It was people getting a ketamine infusion and doing therapy with a therapist under the
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  effects of ketamine. And they called it like an abreactive agent, you know, to bring these
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  things forth. And so the earliest conceptualization of how you might use ketamine for
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  mental health purposes was as an accelerant to psychotherapy.
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  And so the strangeness of this is if you kind of track it back to what happened after that
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  with, you know, Prozac coming out and all of this sort of stuff with big pharma is there
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  really was this different narrative eventually of chemical imbalance theory, et cetera.
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  And so there's tons of research on mechanistic stuff with ketamine, but really quality high
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  level research associated with KAP is sparse.
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  There's a handful of really great studies, but it's hard to say KAP because it's hard to
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  study psychotherapy interventions in general that aren't protocolized.
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  And KAP as a modality is not necessarily something that's completely protocolized and
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  concreted yet. It's still something that we use elements of.
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  IFS is very heavy and ketamine assisted psychotherapy, but a lot of elements from
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  different therapeutic modalities in KAP to be able to to do that work.
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  And so I think until KAP really becomes a thing, if you will, like this is really what
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  this intervention is, that's which is going to take a lot of development.
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  It's going to be extremely challenging to actually study it in a much more robust way.
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  And so these head to heads between just getting ketamine and doing ketamine assisted
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  psychotherapy, there's only just a handful of studies.
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  And of course, the data is very promising in that.
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  But what we end up seeing, you know, anecdotally, clinically, is that it makes a huge
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  difference. And what I'll say about how I know that is, is that when we started the
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  clinic, we did like a lot of things that everybody else did because, you know, we were
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  just really kind of rookies at it.
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  And so we did offer patients to just come get a ketamine infusion and we offered people
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  to do ketamine assisted psychotherapy.
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  And then we had those pools of data.
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  And after about a year, our head psychologist, we had this meeting and he showed me the
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  data and he was just like, it is unethical to just be giving people a ketamine infusion
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  because what I can show you is that these patients don't get better in any true sense.
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  They have temporary reductions.
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  And then we kind of milk that along with infusions.
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  These patients that are doing psychotherapy as well, they're doing a treatment series.
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  Maybe they do one or two sessions throughout that next year, but they actually get better
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  and sustain that change.
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  And so oftentimes the major difference between just receiving a ketamine infusion and
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  doing ketamine assisted psychotherapy is what you see in the long term, which is
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  obviously the most challenging phase of research, you know, to actually get data on
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  someone a year or two years after the entire process.
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  And so those take large scale studies to be able to actually get that data where you
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  will see the main difference between KAP and just ketamine infusions or receiving
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  ketamine in any other way.
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  I'm curious about people who are worried about kind of negative side effects or what
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  could happen.
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  What would you say to those kind of questions?
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  In regards to what it can be like experientially or kind of maybe a fear of a quote
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  bad trip or what's like a bad trip or yeah.
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  The main thing is psychotherapeutic support.
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  So unfortunately, it's common to find practices that will give someone, you know, an
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  intramuscular injection of ketamine and then walk out of the room and let them self
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  support. For us, we do an IV ketamine infusion.
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  So if at any point the level of ketamine is a little overwhelming or just not quite
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  right, we can adjust that real time.
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  We can stop at any time.
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  And with the psychotherapeutic support, if at any point somebody meets his rough patch,
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  well, chances are that's where the real therapy work is going to be done.
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  And so that's not necessarily a negative when those things come up, when some trauma
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  actually emerges. That's actually an opportunity.
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  So we don't see that as a negative when we're doing KAP by any means.
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  Certainly can be challenging, but we can be very careful about that exposure to that
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  trauma because we can really titrate not only the level of ketamine that somebody is
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  experiencing, but also they're working with a therapist where if all of a sudden the
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  therapist realizes like, hey, this is just not productive at this point, it's just
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  dysregulating, very much like probably what you see with EMDR.
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  But to be able to have a read on this because you did a solid intake with somebody, you
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  know kind of what their capacity is right now.
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  We can either stop that process, we can redirect it.
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  And so if you're well psychotherapeutically supported and you're doing administration
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  that allows you to be able to alter the level of experience, we just don't really have
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  this problem. Any anxiety or challenges or just anything that's happening
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  experientially under ketamine that comes up, we can either make that productive or
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  stop it if it's not productive.
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  And so we don't really deal with that.
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  But I definitely do think that that concern isn't invalid by any means, because if
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  somebody is, you know, they're getting a telehealth ketamine prescription to their
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  house and they're just on their couch by themselves while trauma emerges and they're in
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  that process, that can be re-traumatized.
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  So I don't think that that concern is invalid.
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  I just think that the concern becomes much different when you're actually doing it
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  correctly.
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  Yeah, I'm hearing that loud and clear.
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  I appreciate that perspective.
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  So I want to go back to this part in your story where you talked about the fact that
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  you really never intended to open up your own practice or anything like that.
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  You just wanted to do the thing, but you couldn't find the thing that fit for you.
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  So now that you have done some of this, what has that entrepreneur journey been like for
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  you?
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  Oh, I mean, you know, it's been hard.
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  I've done many, many challenging things in regards to patient care.
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  All that feels really comfortable, you know, to do things that are uncomfortable.
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  And that means there's something new or.
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  But this is an extremely challenging and highly competitive industry.
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  And so a lot of the things when we first started the clinic, I would go talk to
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  psychiatrists about what we would do.
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  Yeah.
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  And like they would kick me out of their office like they would not want to hear, you
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  know, what I was talking about.
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  They thought I was crazy.
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  They're like, see, all brainwashing people and, you know, whatever it may be.
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  And so weird ways of interpreting what we were doing.
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  And also when I would present the data to them and being like, hey, look, you know,
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  83% of our patients are subclinical after a treatment series like this is really, really
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  effective, particularly in suicidality.
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  And so maybe instead of sending someone inpatient, you could send them to us if you
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  don't really want to do that, et cetera.
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  They, they didn't buy it.
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  Right.
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  Like it just, it's, you know, I didn't learn about this in school.
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  So it was very challenging to network with other clinicians or to get any kind of
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  referrals, unless the people kind of came just from hearing about it via other means.
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  And then in regards to like kind of competition, you know, when we first
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  started, there wasn't such thing as a telehealth prescriber that would just
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  send people ketamine to their home.
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  It didn't exist.
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  And so some of these things that have emerged and then, you know, challenges
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  with the FDA, with MDMA assisted psychotherapy.
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  So we were right in line to be one of the first MDMA assisted psychotherapy
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  providers in the nation.
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  And then the FDA just, you know, dropped it.
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  And so it's like the challenges around being in a novel market have been, you
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  know, an emotional rollercoaster for sure.
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  What I'm trying to say is, is that when you have built something that has the
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  ability to, in general, take somebody from extremely distressed and suicidal to
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  subclinical, and they'll likely maintain that over time, the fact that it's
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  challenging to kind of have that be believed or to even when you have hard
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  data on it or otherwise is very weird.
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  Usually when you build an amazing product, it's not that hard to market
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  and, you know, kind of put out there.
• 21:45
  And so how new this whole industry is and how we have no culture around
• 21:50
  psychedelics in America really, and that there's been so much drug disinformation
• 21:53
  and all of the things that we contend with.
• 21:57
  Where I come from, something becomes standard of care when there's enough
• 22:00
  research to say that this is now the thing, you know, this antibiotic should
• 22:04
  be the one that you use for this specific condition because we've found
• 22:07
  that this one works the best.
• 22:08
  Well, if you go to UpToDate, the website where it says what essential
• 22:11
  standards of care are, and you look under treatment-resistant depression,
• 22:15
  the first thing listed is ketamine-assisted psychotherapy.
• 22:17
  But if you ask the average clinician, you know, what they think about this,
• 22:21
  they'll just have their own personal opinion.
• 22:22
  And maybe I don't really refer to that or whatever.
• 22:24
  That's not the environment I come from.
• 22:26
  You do what is best in those research and standard of care,
• 22:29
  not your personal opinion.
• 22:31
  And, you know, there's not any room for that where I come from.
• 22:34
  But anyway, you know, I guess my point is, is we still are in a phase where,
• 22:38
  you know, people are taking their personal opinion towards this versus what the
• 22:41
  hard data says about, you know, what is kind of most effective or most indicated
• 22:44
  at a given time for a certain condition.
• 22:46
  And so very challenging landscape right now to essentially figure out how to
• 22:51
  network with other clinicians and how to, you know, do this whole thing,
• 22:55
  keep the place afloat.
• 22:56
  And then of course, dynamic leadership.
• 22:59
  So I manage, you know, paramedics and nurses and nurse practitioners and
• 23:02
  therapists, like all of these people require extremely different management
• 23:08
  styles, you know, obviously managing a therapist who might really need a lot of
• 23:12
  emotional support, making sure that they're not getting overwhelmed or burnt
• 23:15
  out with the hard work that we do versus, you know, how the management style that
• 23:19
  a nurse is used to is very different.
• 23:22
  And so I've kind of been through the bootcamp of learning leadership when I
• 23:28
  was never planning on doing that.
• 23:29
  I was just a decent clinician myself.
• 23:30
  I, you know, I didn't really have a whole lot of experience leading anybody.
• 23:33
  So now all of a sudden it's like, well, you know, you're a leader now.
• 23:35
  And so, you know, better get used to it.
• 23:38
  Yeah.
• 23:38
  Trial by fire.
• 23:39
  Yeah.
• 23:40
  Wow.
• 23:40
  Are these services covered by insurance?
• 23:43
  The therapy services sometimes, you know, you can get reimbursement for, but
• 23:47
  every now and then we'll see someone get, you know, full reimbursement, but there
• 23:50
  isn't yet a specific CPT code for ketamine assisted psychotherapy and even mental
• 23:56
  health indications for ketamine administration are not on label.
• 23:59
  And so it doesn't matter that there's hundreds of studies to say that it's
• 24:03
  effective, there hasn't been the millions of dollars dropped on making that actually
• 24:10
  on the label so that you can, you know, then insurances use that even though the
• 24:14
  majority of medications are prescribed off label, which is a very broken system
• 24:18
  when the majority of medications are not on label, but, you know, we obviously need
• 24:21
  some change around that, but only as the insurance companies use that as a means
• 24:25
  to say this isn't covered, you know, when it's been driven home for, you know,
• 24:30
  decades that, you know, this is something that is useful, but there's trillion dollar
• 24:34
  industry trying to keep ketamine from, you know, basically disrupting the
• 24:38
  pharmaceutical industry, you know, this is a major threat.
• 24:41
  And so I think that there's substantial lobbying against, you know, this and in
• 24:45
  all completely fair world, it would be covered by insurance, of course, but
• 24:50
  there's, there's more to play.
• 24:52
  I would love to maybe hear a last thought for you.
• 24:57
  If there's one thing that you could leave with someone about pursuing what you
• 25:01
  believe in or starting your own business or just about ketamine assisted
• 25:06
  psychotherapy, what would be your sort of final thought you want to leave people
• 25:10
  with?
• 25:11
  I don't know the exact quote, but you know, it's like the people who are crazy
• 25:14
  enough to think they can change the world.
• 25:15
  You know, tend to actually do something.
• 25:17
  Yeah.
• 25:17
  I do feel like this journey has been that way because it's like, yeah, I wasn't an
• 25:21
  entrepreneur.
• 25:22
  Like this is, you know, I had done some mental health work, but you know, was not
• 25:26
  someone with 20 years of, you know, psychotherapy experience by any means.
• 25:29
  But I saw the need.
• 25:31
  I knew that no one else was going to fill it.
• 25:33
  And I just called a place and got a lease on a thing and went to an auction and got
• 25:39
  some chairs and some paintings and, you know, whatever we needed for the clinic
• 25:42
  and bought it at super low rate.
• 25:44
  It was started on an extremely small budget and just got rolling really small
• 25:48
  and built it from there and was scrappy about it.
• 25:51
  I guess my point is, is that I think there's so many ideas that will just, you
• 25:55
  know, die in the graveyard that people won't ever act on and signing up for
• 25:59
  entrepreneurial journey is not signing up to have everything perfect and not get
• 26:03
  punched in the chin along the way.
• 26:04
  It is just getting back up over and over and over again, because it's not going to
• 26:08
  be easy, especially if you're in a novel market and doing anything really worth
• 26:12
  doing.
• 26:13
  I mean, there it isn't an extremely profitable idea to actually help people
• 26:17
  in an extremely big way versus like kind of, you know, keeping them on some sort
• 26:21
  of trickle here, you know, when you're trying to do something that's extremely
• 26:24
  important, you're just going to face extreme challenges as well.
• 26:28
  And so you have to go into it with a mindset that like, I'm going to get
• 26:32
  punched in the chin repeatedly and every single day I'm going to come back in and
• 26:36
  try to bring that same energy to my team that, you know, we can actually continue
• 26:42
  on despite all of those challenges.
• 26:44
  And so, yes, that isn't in everybody inherently, but I do think it's something
• 26:49
  that can be built, you know, it's something that can grow through time.
• 26:52
  And so I think when I first started, I didn't feel, I only had like a little
• 26:55
  flicker of that and it's just like really grown into a flame over the years
• 26:59
  of like, it just doesn't matter, you know, like in regards to all of the
• 27:02
  challenges that we're going to face along the way, I feel like I've become tone
• 27:06
  deaf to all of those and instead just hyper-focused on the things that actually
• 27:10
  are working and the people who actually do want to talk to us and the people
• 27:13
  that we actually are helping.
• 27:14
  And so, you know, I think that's like the attitude that anybody thinking
• 27:18
  about doing anything in a big way, that's really new or novel, like just
• 27:21
  all the criticism and all of the challenges and waking up and seeing
• 27:25
  that, you know, the bank account's low and I've got payroll coming soon.
• 27:28
  And just all of those things, you have to sign up for that fun adventure.
• 27:31
  And I think that a restoration of the sense of adventure in this entire thing
• 27:34
  is, is something that's going to be a part of my life.