Sage Integrative Health

[00:00:00] Greg Kubin: Welcome to Business Trip. A podcast about psychedelic entrepreneurship. Psychedelic medicine is transforming mental, physical, and spiritual health and entrepreneurship will be key to expanding access. Business Trip explores the business models and origin stories of the most interesting companies in psychedelics. I'm Greg Kubin and I'll be co-hosting with Matias

[00:00:29] Serebrinsky. Today's episode is with Genesee Herzberg, the co-founder of Sage integrative health. Sage is a holistic mental health clinic based in Berkeley, California, that offers a range of services, including ketamine therapy, psychotherapy, somatic therapy, acupuncture, and other modalities. Genesee is both a psychologist at Sage, as well as an owner.

[00:00:52] The fact that Genesee wears both of these hats makes for a really broad and nuanced conversation and fun fact, she's also a therapist for the MDMA therapy for PTSD trials, sponsored by MAPS. In the first half of the episode, we talk about ketamine assisted therapy and the healing journey. This includes Genesee's protocol,

[00:01:11] the difference between high dose and low dose ketamine experiences, how trauma lives in the body and how to work with that trauma. In the second half, we transitioned into the business stuff and chat about how Genesee actually runs Sage Integrative Health after bootstrapping it and raising no outside funding to date, Genesee shares about what it takes to get a for-profit clinic off the ground.

[00:01:33] We also get the chance to talk to Genesee about the nonprofit she created, Sage Institute, where she uses a sliding scale payment structure to increase access to Sage's services. Like Sage integrative health, you could say today's episode is truly an integrative experience. We get to see what it's like to build a psychedelic clinic from the perspective of someone who is a healer, community leader, and entrepreneur.

[00:01:58] And now to the episode.

[00:02:09] Matias Serebrinsky: Welcome to the Business Trip podcast. Great to have you here. What is ketamine assisted psychotherapy and how does it work? 

[00:02:17] Genesee Herzberg: Thank you. It's lovely to be here. And in terms of ketamine assisted therapy, ketamine is one of the few currently legal psychedelics on the market right now. It's available by prescription from a physician or a psychiatric nurse practitioner.

[00:02:34] And there are two different ways that it shows up in the, in the market right now, one of them is through infusion centers. So, so that's not ketamine assisted therapy. It's just ketamine infusion, where people go in, are hooked up to an Ivy and get an infusion, which typically happens maybe twice a week for the first few weeks and then slows down over time.

[00:02:53] And that impacts the biochemistry of the person and seems to be helpful for a lot of people with treatment resistant depression, even without the therapy component. But what we found, we hold an integration group, actually, for anyone who's working with ketamine. And when any therapeutic way, including those who don't do it with therapy.

[00:03:12] And a lot of times in those settings, there's just a lack of safety, a lack of preparation, a lack of, um, support through the experience, which, which can be quite agitating. It can also be quite profound, but ketamine is a psychedelic that can bring people into very altered states of consciousness and without a supportive person there, it can, it can be scary and even traumatizing for some people.

[00:03:37] So ketamine assisted therapy as distinct from just ketamine infusions is a process of working in psychotherapy with ketamine as an adjunct. So typically someone meets to with first a prescriber and who assesses their viability as a ketamine patient and prescribes the ketamine if it seems like a good fit.

[00:03:58] It can be prescribed through either sublingual lozenges, or through intramuscular injection, or again, as an IV treatment. And then the client goes on to work with a therapist, doing preparation sessions, where they learn about the medicine itself and how it might impact them. They also learn about the course of treatment and they develop a sense of safety with the therapist, learn about how to prepare themselves mentally, emotionally, physically, spiritually, et cetera.

[00:04:27] So after however many preparation sessions we determine is appropriate, people then have a ketamine assisted therapy session, which for us is three hours long. And in that session, the client ingests the ketamine either through the lozenge that I mentioned earlier, or they're injected and say, will end up having a ketamine experience.

[00:04:48] And, and that can vary from low dose where they're still present in the room and able to talk to the therapist and we call that psycholytic psychotherapy or higher dose where they're more going inwards, wearing eye shades and listening to music and talk more of a full, almost dissociative experience.

[00:05:05] Many people have mystical experiences in these states. And then as they're coming down, the therapist and client talk about the experience and start to integrate it. And then there are integration sessions afterwards. We usually like to do at least one integration session about one to three days after the ketamine session while it's still fresh.

[00:05:23] And then we'll follow up with usually at least another one or two integration sessions throughout. And often people go through a number of rounds of this treatment. It can be very impactful for people. It can really shift them out of deep depressions and also help to open up and deepen the therapy itself.

[00:05:38] But often people need, at least I would say six to eight more ketamine sessions over the course of sometimes it's, it's a shorter period of time, like four to six weeks. Then sometimes it ends up being a longer period of time, like a number of months, or even years. 

[00:05:54] Matias Serebrinsky: You mentioned that you work with patients in a low dose or psycholytic dose, and then it could be a high dose or psychedelic dose.

[00:06:02] How do you define which patient gets the psycholytic or the psychedelic 

[00:06:07] dose?

[00:06:07] Genesee Herzberg: So we always start with a lower dose. So a psycholytic dose and the psychiatrist will determine what that is for each individual client, but we're aiming towards a psycholytic session because those can be incredibly valuable for everyone.

[00:06:22] So we want to get a sense of how does this work for this particular client? Are they able to communicate with us in that state? Does it seem to really open up and support the treatment and is it helping them in terms of their mood and their symptoms? So we'll, we'll have at least the first session as a lower dose session.

[00:06:41] Some people will love that and want to stay there. And other people will like that. Want to continue there for a while with an ongoing curiosity about the higher dose.

[00:06:51] Matias Serebrinsky: It's interesting that you have this wiggle room, so to speak. I think about how clinical trials are being done for different psychedelic therapies.

[00:07:00] And I would say that it's usually higher those more of a psychedelic dose. So arguably an advantage of ketamine and being prescribed off label is that you can play with that and explore and, and try different things. 

[00:07:13] Genesee Herzberg: Absolutely. Yeah. And I would equate low dose ketamine to more like MDMA, which is more psycholytic in nature.

[00:07:20] Typically you talk and process their experiences throughout. Sometimes they will have fully inward mystical experiences, but more often it's a process. And more often it's like psycholytic therapy where psilocybin more often, like you're saying is more of a high dose psychedelic experience. So ketamine kind of gets the best of both worlds in a way.

[00:07:40] Matias Serebrinsky: I'm curious on what is that patient or client journey? How did it go from a non psychedelic session to then doing a ketamine assisted therapy session to then going back to a non psychedelic session or integration, but also the idea that maybe they will go back a year later into our ketamine assisted therapy sessions.

[00:08:01] So what is that typical client journey? 

[00:08:04] Genesee Herzberg: Yeah. So I'm going to sort of separate these into sort of two different types of clients. Some of them come in knowing that they want to do ketamine assisted therapy. And we are working towards that from the beginning and they do more frequent ketamine sessions throughout other clients are coming in either they're just coming in for regular therapy.

[00:08:24] And this is something that might come up as we talk about what they're struggling with. I might think, oh, ketamine might be a useful treatment for you. So it might give them some information about it and see if it's something they're interested in. And others come in knowing they want ketamine assisted therapy, but really in the context of an ongoing therapy treatment.

[00:08:42] So for either of those two types of clients, we'll start off in regular therapy and work together for some time often it's it's weeks or, or even months. Or even a year or so before they come around to being ready, I've noticed that just based on the media and the way that psychedelics have been portrayed over the years, particularly with the drug war, particularly for certain populations who are particularly oppressed by the drug war, like people of color, for example, who see mass incarceration as a result of petty drug charges and are like, I'm just going to stay away from that.

[00:09:18] So for some people, it just takes some time for them to get used to the idea, even if they have found me, because I offer psychedelic therapy, they want to do it. There's still a lot to unpack around their fears and concerns and yeah. Ways that it might one, one big fear that I've seen as a fear of unraveling that they've.

[00:09:38] Worked so hard to get to this place, especially people with a lot of trauma in their backgrounds and they, they they're scared of what would happen if they let go and ketamine and most psychedelics really have this effect of softening the defenses and opening people up to what's underneath. And that can be very scary for people.

[00:09:58] So, so sometimes we're spending a lot of time working with that, or other fears might be that they'll embarrass themselves or do something stupid or embarrassing or inappropriate that it will impact their brain in the longterm. So, yeah. Keep typing back to that. I don't know. Remember this advertisement a while back coming from the government and the old drug war back in the eighties of like, this is your brain on drugs and they crack an egg into a pan and it's they're frying.

[00:10:26] I mean, that, that I think is just so ingrained in many people's minds. And so we have to undo those perceptions. So yeah, I can take it can take some time for some folks, less time for others. And then eventually we'll, we'll get started with the ketamine work. Because we've been working together for awhile, the safety and trust is already established and we'll have a session and spend whatever time we need integrating it because ketamine is a shorter acting drug and also has an impact on memory

[00:10:52] sometimes it's harder for people to remember the specifics of the sessions, especially at higher doses. And so I see it as my job to take really good notes. And also to help people to circle back to often the very potent and meaningful experiences that they had. So some of integration is going back, remembering what happened, tying it to their current lives and meaning some of it is a sematic integration of working with the ways that other trauma lives in their body and helping them to feel and express and move through those feelings.

[00:11:26] And then part of it is, is something you might call implementation. Like a lot of times people get insights about how to change their lives or how to redirect their lives in a healthier way. And so supporting people and really following through on those insights. 

[00:11:41] You mentioned 

[00:11:42] Matias Serebrinsky: the fear of unraveling. I heard this many times from folks that are not experienced with psychedelic medicine and what I'm hearing is that there is a part that is bringing that fear into a awareness,

[00:11:55] but my question for you is what happens after the fear comes into awareness? Like how do you work with a client to overcome. 

[00:12:05] Genesee Herzberg: Yeah. So a lot of it's really just making space for the fear like that. It's generally a part of them. I like to think of this thanky is manifesting in different parts of ourselves that, that developed in our childhood in response to the conditions and adopted to different circumstances.

[00:12:22] So this, I, I see as sort of a protector part that is worked really hard. Like I said to hold people together and, and often that protective part just needs to be heard, needs to be able to express its fears and concerns and be understood in them. So a piece of it is just a real receptivity to all of their feelings and fears and worst case scenarios and just helping them to voice those things.

[00:12:49] And acknowledging them is as legitimate on some level. And then also offering some psychoeducation around what I've actually seen. The primary time that you see people kind of fully unraveling as a result of these substances. And it's not, it does happen on rare occasion, but it does happen more often with the tryptamines like psilocybin, LSD, and DMT.

[00:13:12] And it's more often when someone has a family history of psychosis and or past experiences of, of psychosis and when those are unmanaged. So once we've determined that we think it's safe for them to move forward, we don't foresee that as being a risk and we've done everything we can to manage that potential risk.

[00:13:31] So I'll let them know that. And yeah, just tell them about what could actually happen. Like it could feel in a session. Their guard is down. And like they're more open to talking about their trauma, for example, or they're more open to talking about the relationship and their feelings towards me, or more open to revealing certain secrets or aspects of their experience or history that they typically keep hidden because they have a lot of shame around them.

[00:13:58] And then we can work collaboratively to think about, are there ways that we actually want to work together to protect them from that? Are there certain boundaries that they want me to help them hold in the session when their guard is down? Are there certain places that they don't want to go and. Here than going in any one of those directions, then also say we made an agreement earlier that you didn't want to go here.

[00:14:21] So that's, let's pause this session and kind of shift to another topic and we can come back to it and think about whether this is really something you want to be talking about in our next session. So there's a part that wants to bring those feelings out often. But another part that really doesn't, I guess, one piece of what we're doing here is working with these protective parts to ensure that they feel comfortable stepping into the work and knowing that I'm going to support them in not going places that they don't want to go.

[00:14:51] And, and also in knowing that this fear of unraveling is, is not likely given the particular context assessment, who they are as individuals. 

[00:15:03] Greg Kubin: Would you say that the fear of unraveling and those parts that people tend to protect would be called shadow work? Is that how you would define that? 

[00:15:14] Genesee Herzberg: Yeah. I mean, the parts that people tend to protect it definitely could, could be termed in union terms, shadow elements.

[00:15:23] So elements of the personality, the tends to disidentify with, because they were rejected or disconfirmed in our early childhood. And so they live in the psyche dissociated parts of ourselves. And interestingly, sometimes those parts are, are shameful parts or are traumatized. Parts are wounded parts.

[00:15:44] Sometimes those parts are just beautiful parts of ourselves charismatic and outgoing. And sometimes they hold our vitality because in our childhood there wasn't space for us to be those ways. Yeah. 

[00:15:58] Greg Kubin: And I guess on that note, we, Matias and I spend a lot of time speaking with companies that are pursuing the FDA pathway.

[00:16:06] And in that world, there's such a strong tie between a company developing a therapy. Going after a specific indication and that indication in the DSM manual, it could be major depressive disorder, generalized anxiety disorder. And then I look on the other side of the spectrum, kind of to what we're talking about here, about this idea that all humans have shadows and parts of ourselves that may have experienced trauma.

[00:16:33] And I'm kind of trying to reconcile like the different approaches between a company that's going after a specific indication versus the way you're speaking about it, where it's like, this is the human condition. And like, I'm wondering when you speak to a patient, are you diagnosing them with the specific indications or do you kind of look at them as an individual who is looking to heal parts of themselves?

[00:16:57] Like any human. 

[00:16:59] Genesee Herzberg: I really appreciate this question. It speaks to, in my mind, a real, I think split in our culture where on the one hand we have the FDA approval system. We have the DSM diagnostic manual, and we have a certain tradition within psychology and psychiatry that are very symptoms focused, diagnosis focused, and often looking to very specific short-term treatments, including medications, and also certain quote unquote evidence-based treatments to cure a disease, which really often looks like just alleviating symptoms.

[00:17:38] And then we have many, many people in psychotherapy ranging from psychiatrists to psychologists, to marriage and family therapists, social workers who see human suffering in a very different way. I see it as a spectrum and something that we all experience in one way or another. I think about it as mental health privilege, actually that some people are born into families where there's just, they're better adjusted there.

[00:18:06] They're more psychologically healthy. They have more often resources. And, and so there's, there's less intergenerational trauma, less of a history of trauma. And for those people, they may have less acute symptoms and less kind of diagnosable symptoms or illnesses. And then there are those who were born into situations that just had incredible amounts of trauma and violence and neglect and abuse and structural oppression and racism, and coming out of an environment like that.

[00:18:38] There's just, it's inevitable that you're going to experience a significant symptoms of a wide range of qualities. And so there is that kind of mental health exists on a spectrum. And for all of us, I actually think about this as, as relational trauma. Most of us. Some things happen in our early relationships with our parents that left certain parts of ourselves feeling unseen or rejected or dismissed, and those parts go into the shadow realms.

[00:19:12] And so there is this process of working to integrate the wholeness of our person and our personality that I think is important growth work for anyone, no matter where you exist on the spectrum. So I would just to add that in my work, I, as a psychologist, I have to hold both. When, in order to do this work with ketamine, it, it is a schedule three controlled substance, and we do need to be able to justify our use of it to the FDA or anyone who were to audit our files.

[00:19:45] And so we find a DSM diagnosis that is most appropriate to the particular individual and most people who are coming in suffering of something that fits within the DSM. And so whether it's generalized anxiety or depression or something of the sort. So, so we do have to rely on. I find the more, more structural ways of doing things, even if that's not where our underlying understanding of this work lives.

[00:20:11] And I think that's what's happening in the clinical trials as well. I think that they are really needing to a cross their T's dot their I's and do this in a way that's going to be generally acceptable by the FDA, by the DEA, by the board of psychology board of psychiatry. And, and it's also just how drug development works is you, you develop a treatment for a specific indication.

[00:20:35] And so in these cases, they're, they're taking MDMA for example, and saying, which indication is, is this going to be most effective for? And we, for the most part, agree within the community, that that PTSD is a really good fit for that, or psilocybin might be a really good fit for end of life anxiety. So, so it makes sense that that's how the studies are happening right now.

[00:20:57] And once we move into legalization and commercialization and the availability of using the MDMA and psilocybin in our practices, we'll be able to start using them off label for a number of different indications. 

[00:21:12] Matias Serebrinsky: The other component of these medicines moving from kind of FDA clinical trials to commercialization is the opportunity to integrate them with other treatments could be body work or EMDR on that is one of the things that Sage has.

[00:21:29] Right. And so I'm curious on how you think about the integration of different therapies with ketamine assisted therapy. This 

[00:21:39] Genesee Herzberg: is one of the topics that I get very excited about. I just think that there's so much potential there for integrating these different modalities, particularly ones that focus more on the body with ones that focus more on the minds, the emotional processes and the psyche.

[00:21:55] And so I've really started off that exploration in, in my own work and found that bringing in body work and bringing in acupuncture to my psychedelic work was incredibly, uh, helpful, and well, one of the ways is in kind of opening up those parts of ourselves that don't want to let go. Like sometimes psychedelics, soften those defenses right away, but other times they can actually tighten them.

[00:22:23] Most of those parts can come on board and tight, even more against the possibility of opening up and acupuncture. For example, has just been incredibly helpful and working on a somatic level to start to help those areas of tension and constriction to. To relax on the other end, when it comes to the integration and implementation and the preparation modalities like naturopathic medicine and nutrition can be really helpful.

[00:22:49] There's the term dieta that comes from plant medicine work in Latin America. And that often entails really limiting the foods and toxins that we put in our body in preparation for psychedelic sessions. And, and some say it creates more of an open channel to receive the medicine. So having a professional help you think through how best to do that can be really helpful.

[00:23:12] And then on the other hand, people often get messages around needing to improve their health and a various ways both how they eat, but also get a real assessment of what's happening in internally and where their neurochemistry might be off. And then also in terms of their daily life practices, like exercising and meditation.

[00:23:31] And so having a practitioner to help you think through those sayings, coach you and following through on those intentions can be really helpful. 

[00:23:40] Greg Kubin: I was speaking with someone recently who was sharing that in her ketamine, somatic, bodywork, she was accessing all sorts of memories, even perinatal memories. And that whole concept to me is kind of mind blowing.

[00:23:56] Can you speak to that in terms of what you've experienced or with your clients. 

[00:24:00] Genesee Herzberg: It sure is. Yeah. I mean, I've seen it in everything from holotropic breathwork to really all of the psychedelics I've worked with. MDMA, psilocybin, Ayahuasca, more in my own experiences and then ketamine in my work. And yeah, there are for certain people in a way that the medicine seems to bypass our conscious memory and take us into places that I see it feel, it seemed to be more of a somatic memory of the ways that the body holds our trauma in our system and allow us to touch into those places.

[00:24:39] Often it looks like actually moving into the position that the body made in order to protect themselves in that moment or the position that they got frozen in. Peter Levine, who developed somatic experiencing a modality that's for both psychotherapists, but also non psychotherapists of working with trauma. And the body eats sort of looks at the ways that animals respond to trauma and describes the ways that when something happens, say a deer is chased by a cheetah, the they escape, the deer has been in this fight or flight mode.

[00:25:15] And it then is safe. And what they do is they shake it off. Their system is able to naturally just shake off the trauma. And so it doesn't, they don't go on to carry it in their bodies. Where for us and humans and some animals too, in various circumstances. The opportunity to just shake it off. Isn't there, maybe it's a chronic experience or maybe they're in- utero and that's not possible, or going through the birth canal or just in a very infantile state where the threat is consistent, then it lives in the body not having been properly

[00:25:50] released or attended to. And so yeah, often these medicines bring us back into that, that frozen or stuck place. And it's almost like bringing the way I've experienced it is bringing oxygen into each one of those frozen cells and almost like touching them with love and safety and allowing them to slowly take that in and to slowly release themselves.

[00:26:19] And the release can look anything from a really subtle process of like slow unfurling to a more dramatic process of shaking or sobbing or screaming or pushing. I had one experience where this was actually in a holotropic breath work workshop. And this was myself as, as the experience. And I was taken back to an experience that felt like a combination of a prenatal trauma with a past life trauma.

[00:26:53] I mean, I have no idea about the past life piece, but I was actually envisioning myself on a, like, almost like a cross with my hands tied down, being persecuted. And that felt actually like another iteration. If we think of sort of the holographic nature of the universe, or how does Stan Grof talk about it.

[00:27:12] These kinds of multiple matrices are different, different levels of experience that happen from the biological developmental, prenatal, past life and relational and all sort of combined themselves into one complex. And so here I was experiencing the various elements of, of this one complex as it lived in my body and the person who was holding space for me, I asked if they could hold down my hands just to kind of amplify that feeling of being held down.

[00:27:43] And I breathed into that for a while. And then eventually. I built up the courage to break myself free from it and came out, making this giant roar, like a lion and just full on, like broke out and regained my power. And it was incredibly empowering and incredibly relieving and healing at levels that I'm not sure I will ever, ever fully understand.

[00:28:10] Greg Kubin: And so when you have a client who is experiencing having a, you would call it like a mystical experience, a spiritual experience, what do you believe your role is to be in that moment? Well, 

[00:28:21] Genesee Herzberg: so I'll distinguish there. I think, I think what we were just talking about may not, it may be experiences mystical, but it may not be like a client recently went into a place of feeling.

[00:28:33] The image that came to mind was an infant just like left completely alone. And it just totally alone in utter despair. And that she was feeling that in her body, she was sobbing and, and that image was just what was there and stuck around. And she was able to verbalize it. This was on a lower dose. So I felt like my role there was to be with her, support her in her experience to make contact somatically, physically.

[00:29:00] We talk about touch prior to these sessions and get consent around it. And if the client is open to it, it can be a very profound way of, of offering a sense of containment and holding and love in these really challenging places. And then later on, you spent time unpacking and trying to understand what was happening.

[00:29:20] Mystical experiences on the other hands, more often seem to show up in higher dose of psychedelic levels. And often people have their eyeshades and their music on. And so I see my role throughout those sessions, as in holding a quiet, open, receptive, tuned spaciousness, I'm sitting in meditation basically, and doing my best to tune into what's going on for them and noticing both what I see.

[00:29:53] And then in terms of like grimaces or body movements that might be coming up, what I feel in myself as a, an aspect of what we call the countertransference. So not the kind of feelings that the therapist takes up in response to the client. And, and sometimes even reveries, like where my mind goes. I'll take note of that as well.

[00:30:14] And some people talk about the field. So it's, it's kind of the energetic field between therapist and clients, and that's a more esoteric term. Not everyone believes in that, but what I've found it to be a very interesting place to explore and stay open to. And, and I'll just take note on all of those things and really try to hold a loving space or wherever they are and often don't know exactly.

[00:30:40] And then they'll come back afterwards and tell me about it. 

[00:30:43] Matias Serebrinsky: You mentioned that you are in a meditative state and I'm increasingly finding a deep relation between meditation and psychedelics either because the ability to stay present with what's happening from the experiencer, but also you're now talking from the practitioner perspective as well.

[00:31:05] So how do you connect these two different modalities, so to speak. 

[00:31:12] Genesee Herzberg: Well, one of the physiological interconnections between the two is that they both tend to decrease activity in what's called the default mode network of the brain. So that's the part of the brain that has attended, or it's actually a connection between different parts of the brain that people have related to that, the ego.

[00:31:35] So the part of us that is aware of ourselves is aware of how we show up in the world. Reviews past interactions thinks about future interactions, and is just generally kind of a self-reflective part. And it can be kind of, ruminative like it's yeah, not it's important in order for us to get along in the world and interact with others.

[00:31:56] And also it can really take us out of the present moment. So both psychedelics and meditation practice tends to decrease activity in, in that network. And so it's almost like the ego gets put aside a little bit and it's people are able to be more just present with whatever is right there. And what I found is that having a consistent meditation practice helps to open up the potential for psychedelic experiences to be deeper, more profound for us to that kind of ego, to, to let go a little bit more and enter into the more unconscious realms or areas of our experience that are harder to typically access.

[00:32:42] And then it can also be incredibly helpful for integration work, where having a preparation and integration work in the preparation work beyond just you starting to center the mind, finding a quiet space within ourselves. It also opens up a space for the emotions or experiences that are likely to come up in the psychedelic session to start to surface.

[00:33:08] Matias Serebrinsky: Absolutely. And I was realizing that when you were talking about by staying present, you can also capture the energy of the room. It's interesting to think that in indigenous communities, the shaman or a medicine woman or medicine man would actually also ingest the medicine. Right. And so I feel like that was the way that they would also connect with what was happening for the experiencer.

[00:33:37] But it's interesting to think in our culture, that's a big no-no. Right. And so how, how you think about that? Do you foresee a future where that changes or how can practitioners go around that? 

[00:33:52] Genesee Herzberg: Yeah. Yeah. I see that huge value and benefit in that for, I think it's one thing that we're lacking in this new phase of psychedelic treatment and that the psychedelic movement, and that was a part of indigenous communities for centuries.

[00:34:10] And then it also was a part of the underground world and, and the, the just psychedelic psychotherapy world prior to criminalization. So yeah, I mean, I, I see the complexities of it as well. When we talk about it, it shows up also when we talk about even just therapists and training, getting to have experiences at the medicine, which I think is vital.

[00:34:32] And I really think you need to know the medicines that you're working with, but I bet it also shows up in this question of being in the room with a client and the extent to which you can drop into their experiences. I think through deep meditation practice, you can get really close to that. And many people say that at a certain point, the psychedelics have really pointed me in the direction I need to go.

[00:34:54] And I don't really need that so much anymore. I, I find that my kind of spiritual practice gets me to the same place or to somewhere very similar. And so, so on some level it may be that spiritual practice alone can, can really help us to tap into those, those states of consciousness and meet our clients. On the other hand and in the rare experiences where I've been able to explore that it's been in community settings, a lot of my kind of experiential training, you could call it.

[00:35:23] And also the support for my work. That's where I get my consultation. It's where I get my, a lot of my learning around this work has been in communities of colleagues and practitioners in those contexts, Scott, and to experience being on the medicine while also supporting others on the medicine. And. Wow.

[00:35:46] I would say in, on a number of occasions, I've just become by far the best healer that I I've ever been. So I think there's a ton of potential there. I hope that our, I, I'm not sure, but I really hope that our systems have become open to that over the years as, as that these medicines become more widely accepted because I, yeah, I think there's a ton of potential. 

[00:36:11] Matias Serebrinsky: Greg, let's talk business.

[00:36:14] Greg Kubin: I'm curious about what it takes to open and operate an independent clinic that works with ketamine. So things like the personnel, the initial investment, the startup process, so to speak. Can you shed some light on in terms of what it took to get Sage off the ground? 

[00:36:32] Genesee Herzberg: Yeah. And I'll actually start with Sage Integrative Health and I'll give you a little distinction between the two.

[00:36:39] So Sage integrative health was the first business that I co-founded with Julie Megler, a psychiatric nurse practitioner and that is the integrative health and psychedelic therapy clinic. And it's a for-profit. And it has a range of different integrative health modalities in addition to psychotherapy and ketamine assisted therapy.

[00:37:01] And then Sage Institute is our non-profit sister organization that offers sliding scale ketamine assisted therapy and other mental health services primarily. So the nonprofit was really intended to bring the prices down so that almost everyone can afford them. So I'll start with Sage integrative health cause that is where we started. I mean, the first thing that Julie and I did kind of in parallel were looking for a space. You need to have a location. Well, these days in COVID, you don't necessarily, it could, hypothetically all be virtual, but for us, and really ongoingly, we felt like we needed a space. And that was quite a process.

[00:37:39] And the city of Berkeley has a lot of zoning and permitting laws that require that basically any building that's zoned residential cannot be converted to a business or a medical zoning because of the housing crisis. So there are very select buildings that have medical permitting at this point or zoning at this point.

[00:37:59] So we had, we had not that many options to choose from. And then ultimately we ended up finding a space that was for sale after looking at many, many rentals and not finding the right fit. We found an old abandoned medical office it was a converted from a house originally and really sweet little neighborhood.

[00:38:18] And it was just what we were looking for. We really wanted our clinic to have a homey, comfortable feel, but it had been abandoned for 20 years. It was felt in the fifties and needed a built renovation. So we got it and did a complete design and renovation and built it out that took geez, probably about a year for that full process.

[00:38:38] Maybe getting permits alone can take months. So then you know, that we did alongside of starting to build a team. And so we just reached out and started to collect different practitioners of different modalities and started an ongoing consultation group. So both imagine into what we wanted the clinic to be, and also to start to feel into what a multidisciplinary integrative and

[00:39:02] consultation and team collaboration might look like. So that, that was kind of a fun project that we got to do on top of these other kind of more logistical pieces. So then there are things like legal and entity formation. So determining what type of corporate structure you want to be and nonprofit, or for-profit also thinking about, we were really interested in alternative governance and finance model.

[00:39:26] Purpose economy is a really good place to go to, to learn more about that, but just ways that we're not stepping into some of the traditional capital models that end up, I think can potentially have a harmful effect on the company as a whole pushing it towards profit over mission. And we wanted to go a different route.

[00:39:47] We wanted to move towards more of a transformational business model. There's also developing a board and obtaining liability insurance, which can be a tricky thing just in terms of offering this very novel modality that a lot of insurance companies don't understand or know how to wrap their heads around.

[00:40:03] And also for our integrative health clinic, finding a company that was willing to insure everything from a massage therapist to an acupuncturist to ketamine assisted therapist. 

[00:40:12] Matias Serebrinsky: You mentioned a lot of logistical and operational things that need to happen to open and operate an independent clinic.

[00:40:20] What's been the hardest things to get done.. Well, 

[00:40:24] Genesee Herzberg: all of the things I mentioned so far were like tedious and annoying and burdensome, but not necessarily hard. So those, if I had gone back, I would have hired an operations manager from the get-go. We bootstrapped it. We didn't let's see, I guess we got one $50,000 private business loan.

[00:40:44] And besides that, we were pretty much just like investing around money and really trying to keep our expenses to a minimum. But going back, I think I would have sought out other sources of financing and hired someone who's really loves doing ops work. So that was challenging. There there's also the, the building of the business and, you know, developing a fee structure and compensation structure.

[00:41:09] And I'm thinking about accessibility, figuring out how to cover your overhead. And that is something that I did on my own. 

[00:41:16] Matias Serebrinsky: So I guess they don't teach you that at CIIS. No, 

[00:41:21] Genesee Herzberg: no. They actually teach you very little about even just starting a private practice. And I was able to find the resources I needed to start a thriving, private practice.

[00:41:30] So prior to opening this group practice, I was doing great with all these things. And so it was like, oh, I'm sure a group practice is just doing more of the same. It'll be fine. And that was a very naive assumption. There's just so much more that goes into running a group practice or a larger clinic. 

[00:41:48] Greg Kubin: Are you still looking for a finance or business person to support you?

[00:41:51] Yeah, if anyone's 

[00:41:52] Genesee Herzberg: interested, please reach out. So 

[00:41:54] Matias Serebrinsky: you mentioned the B word- breakeven. Can we talk a little bit what it means to breakeven in, in a group practice? If someone's thinking about starting one, how many patients at minimum they should have. 

[00:42:10] Genesee Herzberg: So I will, I'll tell you the story of how this worked for us, because I don't consider myself an expert in this area.

[00:42:16] We brought on a number of practitioners, like I said, without any major financing and so no marketing. So we were really just relying on our networks and Julia and I both had substantial mental health networks. And so we were able to bring in referrals that way for therapists and psychiatrists. And we did some minimal social media marketing, but, but didn't have any support in marketing for a while.

[00:42:43] So one of our struggles early on was feeling the practices, particularly about our alternative health providers. They, we weren't hiring them on a salary and we just were basically, we had a fee split and we were paying them for the amount of hours that they worked. So they knew that it may take a while to build their practices, but even so it, it did take a while for some of them.

[00:43:07] We also learned during this time that many people who wanted to join our practice were most interested in our model, they loved what we were doing. They were interested in the community and they were interested in the ketamine assisted therapy, training and support. So they wanted to plug in for those reasons.

[00:43:25] And we're excited to see some clients with us, but working for a group practice, you're going to be paying more in overhead, or you're going to be, you know, your pay will be less because there's, there's a greater overhead cost. And so there's also a motivation for those same practitioners to be having their own private practice on side.

[00:43:43] Eventually we built up a big enough team and really have just, I guess that our name's gotten out there. So we've, we've had a lot of referrals for psychotherapy and ketamine assisted therapy specifically. So previously been able to fill all of our, our mental health providers practices to the point that they're able to work.

[00:44:02] And at that point, that, and so that was probably two years in, I would say when we were finally breaking, even in covering their costs. At that point, we had enough, a little bit of extra money to be able to hire on some additional management help up until this point. It had just been me and Julie running the business.

[00:44:21] And like I said, we don't have all the skillsets necessary. And so we weren't running the business as well as we could. So we brought on and operations consultant and a marketing specialist and, and that has been a huge, huge blessing. And we still are working to get to the place where we can pay Julia and I for our management time.

[00:44:39] So we see clients and get paid that way. But yeah, we're, we're still kind of thinking through our business model, thinking through our compensation model, thinking through the areas of kind of the target populations that we want to serve, to figure out how to get to a place of ultimate profitability and getting to pay Julie and I for our time.

[00:45:00] We're not aiming to become a highly profitable clinic. We are interested in some level of, of expansion, particularly towards the retreat center, but we do want to be able to breakeven. We want to be able to compensate our practitioners as well with potential bonuses, and then we'd love to be able to, to develop some savings, to be able to devote towards a new 

[00:45:21] Greg Kubin: project.

[00:45:22] Have you been able to figure out ways for insurance to cover your ketamine therapy treats? 

[00:45:29] Genesee Herzberg: So, yes, and no. Insurance covers psychotherapy and it covers psychiatry. So our intakes done with the psychiatrists are billed as a typical psychiatric intake and our prep and integration sessions are billed as a typical psychotherapy session. Our ketamine assisted therapy sessions are billed as an extended therapy session.

[00:45:53] It still doesn't cover the full three hours, but people are at least able to get some form of reimbursement. We're not in network on any insurance panels. So if people are getting reimbursement, it's because they have a PPO rather than HMO, which allows for out of network reimbursement. And there's such a wide variety in terms of what that reimbursement looks like.

[00:46:14] So, especially for psychotherapy. So for some people it's maybe $45 that they're getting back a session and for others, they may get up to 150 back a session. So you have very specific. 

[00:46:28] Greg Kubin: You'd also talked about your interest in increasing accessibility and the Sage Institute has a program that has a sliding scale, depending on people's needs.

[00:46:39] Can you kind of tell us about how that works and some stories that you can 

[00:46:43] Genesee Herzberg: tell. So our original idea at Sage health Sage integrative health was to create an integrative health clinic that was also fully accessible to anyone who needed it. And we thought about different models of the heart, like a sliding scale that goes in both directions.

[00:47:00] So beyond just our typical fee for service, you could actually would pay much higher if you had a significantly higher income. And so there's also the idea of a patient assistance fund, where people are just collecting funds that are donated to specifically subsidized lower fee treatments. We weren't able to get either of those programs running successfully.

[00:47:22] We didn't put as much energy in as we could, but it wasn't working out with the kind of resources and capacity that we had at the time. So at that point was when we started thinking maybe we just need a whole other program and one that's a nonprofit 5 0 1 C3 so that we can collect donations and grants tax free.

[00:47:41] So that's where Sage Institute comes in and they're at this point, the money that comes into subsidized client fees and also to cover our overhead is in part from donations, from philanthropy, from foundation grants, that kind of thing. And then in part from client fees, our clients do pay. Uh, fee, but it's much, much lower than market rate.

[00:48:05] So it ranges from $15 to about a hundred and $150 depending on income. And so we do still bring in some client fees and then the other way that we're able to make it work is that we're set up as an internship training program. So we have psychotherapists in training. Typically they've gotten their masters.

[00:48:25] They've or they've finished their graduate programs completely. And they have some experience in psychotherapy, but they still need to gain their hours towards licensure. And that system is set up now, so that, that people in that situation expect to make less than they will once they're licensed while they're gaining their hours towards licensure, while they're receiving supervision and training.

[00:48:49] And we offer a very rigorous training program in psychedelic assisted therapy. So there's a, there's a high demand. There's a lot of people interested in taking part in our program in order to get this two year training in psychedelic work, which, you know, has a market value. I think some of the programs out there costing up to $10,000 for a year long program.

[00:49:09] So, so yeah, that's the set up there. There are still some major flaws or areas that we're working on in part it has to do with just that set up that I described as a whole. If you look at just about any other profession, whether it's someone in the business world coming out of business school, or someone in working as a medical doctor, they had just the tech sector really just coming out of undergrad.

[00:49:37] Their expected salaries are already way up there. They can, they can expect to make far more than a living wage when they've got a master's degree. And for some even just a bachelor's. And here in the mental health field. And I think this has a lot to do with societal perceptions of the, of mental health and seeing it in some ways it was more of a feminized field.

[00:50:00] So, so that plays into it, but also seeing it as, as maybe unnecessary for, for a lot of folks. I think that's changing with COVID when almost everyone is experiencing some form of mental health 

[00:50:10] Greg Kubin: struggle. Where my mind also goes is to the insurance coverage side of things. And that just being such a powerful lever, if it can be tapped, are you optimistic about that in terms of more coverage?

[00:50:24] Genesee Herzberg: I am largely thanks to the efforts of Leah mics and Thea. They are they've created at, see, I forget if they call themselves an official insurance company or a more like a linkage between clinics and insurance companies, but basically to be able to provide insurance coverage for psychedelic assisted therapies.

[00:50:46] So am on their advisory board, their clinical advisory board, and I'm also a Sage integrative health is going to be one of their pilot clinics. So I'm very interested to see how that will roll out what it will look like. I bet they're really prioritizing, wanting to make sure that the services are covered with high standards of practice and also wanting to ensure that doctors and psychotherapists get paid, what they deserve.

[00:51:10] One of the issues with traditional insurance coverage. And the reason that we aren't on any in-network plans is that the reimbursement rates are half the rates that we would charge otherwise, and it just isn't sustainable to it. It doesn't cover our overhead to be able to work at that level of, of revenue.

[00:51:28] And my hope is that as I start to see how effective these treatments are and how in the long run, they reduce expenditure on medical treatments that they'll see that it's to their benefit financially. 

[00:51:40] Matias Serebrinsky: Yeah, the idea of Thea and then becoming a third party administrator and reimbursements through Medicare or Medicaid and the potential approval of MDMA and psilocybin for psychedelic assisted therapy.

[00:51:56] It feels like there are all these waves that in a way are in your favor. So with the idea that entrepreneurship and starting something is always hard. As you've mentioned, this has not been easy at the same time. There are a lot of reasons why to be optimistic in a way. 

[00:52:14] Genesee Herzberg: Yeah, I think so. I mean, we set up our clinic as a ketamine assisted therapy clinic, both of them, but really with the intention of being able to incorporate psilocybin and MDMA as they become legal and, and we see that happening.

[00:52:28] Greg Kubin: We've talked about MDMA therapy, psilocybin therapy, potentially being approved in the next few years. And you having involvement with maps with MDMA therapy, where do you envision beyond the initial indications that they're targeting? Right. MDMA targeting PTSD and psilocybin initially being, um, major depressive disorder and treatment resistant depression.

[00:52:50] How do you plan to incorporate those medicines into your practice? Kind of outside of those indications? Like, are there other indications that are, that you're like, Hm, this would treat this very well. 

[00:53:01] Genesee Herzberg: So for MDMA, I am really excited about its capacity as a relational solve and a relational healing agent. So that can show up in both couples therapy.

[00:53:14] It was, it's been used for decades to support couples therapy and I've seen incredible results that way. So that's, that's one area. And then the other is, you know, one of my dreams that I hope to be able to move towards at some point is an MDMA assisted group therapy to heal cultural trauma. And my hope would be is that that would be for people coming from a variety of racial and cultural backgrounds coming together, perhaps some affinity groups at first to really help people to develop safety, but also coming together.

[00:53:47] And working with their differences and sharing their heart and their experiences and from the state of expanded awareness and expanded empathy. I think that people will be able to really hear each other and take each other in, in a different way. I think there's a huge potential for not just individual healing, but also societal healing.

[00:54:06] There there's a lot more that MDMA can help for me just a lot. I think really most indications it can be supportive and in the context of a really solid therapeutic relationship, but those are my two inspirations at the moment. Psilocybin, again, I think there's a range of possibilities there. I lean towards MDMA as the kind of first line of treatment for anyone who's got any sort of significant trauma history or even major anxiety.

[00:54:33] But psilocybin I see is a beautiful, both personal growth tool. So to treat existential depression, tool to support people again in their end of life anxiety, that the way in which it opens up, one's mind to the reality that's outside of what's directly perceptible. It gives us a sense of the interconnectivity of things.

[00:54:58] It often gives us a sense that there's something larger than ourselves. It connects us deeply to the plants and the animals and the trees. I think that that is a healing for anyone from existential depression to facing death and freaked out about it. And also an atheist to just people wanting to do personal growth work and find more meaning in their lives.

[00:55:22] And so, yeah, I think there there's a ton of potential for, again, not just individual healing, but also healing of our relationships to each other and to the planet, ecological healing. And I just think that's essential in this day and age with what we're facing with climate change. 

[00:55:38] Matias Serebrinsky: We are going to do a couple rapid fire questions.

[00:55:42] Greg Kubin: First rapid fire question. What's your life's purpose? 

[00:55:46] Genesee Herzberg: Well, that's a big one. I mean, I, when I was about 12 years old, imagined into a clinic or an organization that would house a homeless, offer vocational training and offer shelter for, uh, orphans who would then be adopted by the homeless as they went through their healing process.

[00:56:09] So this was just me growing up in the bay area, seeing how many people were struggling. And I just always had this deep commitment to help people in whatever way I could. And now that's changed and shifted over time. But I see myself as here on this earth to create systems and structures, and also through my own healing offerings, to be able to heal individuals and larger systems in all the ways that I can.

[00:56:35] Matias Serebrinsky: My rapid fire question is what will the psychedelic landscape look like five years from 

[00:56:40] Genesee Herzberg: now? I will give you my dream rather than my fear. My dream is that five years from now MDMA and psilocybin will have been legalized for medicalized use and that there will be a number of clinics and hospitals and VA.

[00:56:59] And even private practice offerings that, that are able to offer this work in a way that is client centered and really respects the ongoing slow nature of the work and is not looking for a magic magic pill with a real good sense of quality of care and ethics and inclusion that those clinics will be accessible to anyone who can benefit both financially accessible and also culturally accessible.

[00:57:28] So those have been excluded from the movement in the past will have access and in the way that anyone else does. And at the same time, I imagine the decriminalization and legalization movements moving forward in many states, maybe even across the country, such that not just medical professionals and not just those suffering from medical and mental health issues will have access to working with these medicines and other formats.

[00:57:56] Yeah, that's my hope, I really the kind of the plain and simple vision is that there is integrative and accessible psychedelic clinic in every neighborhood that is available for anyone who's interested and, could benefit. Wow. 

[00:58:11] Matias Serebrinsky: Beautiful. Yeah. 

[00:58:13] Greg Kubin: Let's make it happen.

[00:58:19] That was Genesee Herzberg founder of Sage integrative 

[00:58:23] Matias Serebrinsky: health. Yeah. I like how she talked about companion therapies, somatic work, acupuncture, body work, nutrition. It feels like patients on a, we all are in a healing journey and they're providing a lot more resources than just the ketamine. There is 

[00:58:40] Greg Kubin: going to have to be a fair amount of education societaly and in the medical community to be able to hold space for people, many people who are reporting these types of transpersonal experiences.

[00:58:55] And so one thing I'm thinking about is how do we bridge that gap? How do we raise awareness? How do we raise education? Maybe it's conversations like this. 

[00:59:04] Matias Serebrinsky: Yeah. I also realized that it's so multifaceted, meaning no therapies, no practitioner has exactly the same protocol. And even with the same practitioner, depending on what is happening for the patient in front of them, they change the way that they show up.

[00:59:22] They change their protocols. So, um, there's such a difference between the way that clinical trials are being conducted and how psychedelic medicine will be practiced in the real world. One huge difference with how psychedelic medicine has been practiced for millennia. Is that in indigenous communities, the practitioner, the medicine person, medicine woman, medicine man, actually, is taking the medicine with the person that's experiencing that.

[00:59:49] And in Western culture, that is a huge no-no. And so I wonder if at some point the culture that we are in, we'll be able to raise that and bring it into the. Existing psychedelic therapy protocols. 

[01:00:05] Greg Kubin: The conversation also reminded me about how hard it can be to be both a therapist and a business owner. And the fact that being a therapist on its own is a job and being a business owner and running a business is a job, and how in this psychedelic space, there is really a big need for business people, as well as business tools, things like software to help streamline that process.

[01:00:31] Matias Serebrinsky: You could say that those things will become more important once MDMA gets approved or when COMPASS gets their therapies approved with psilocybin, but in the end today, there's ketamine therapies being offered. And so those tools could be also very useful today. One thing I really liked about the episode is that it feels like a breath of fresh air when it comes to how Genesee's thinking about her approach to building a business.

[01:00:58] We have been talking to founders that are thinking about building million billion dollar companies, and it's all about scale. Whereas with Genesee's share her ambitions are more about impacting a potentially a smaller number of people, but having a great deep impact into those people. So, uh, it made me appreciate the work that she and every other therapist is doing in this space.

[01:01:24] I 

[01:01:24] Greg Kubin: also appreciate the sliding scale payment structure that she's set up for her non-profit Sage Institute and really putting a focus on increasing access to ketamine therapy. And so, um, for any of the listeners out there, if you are interested in donating to Sage Institute, we've dropped a link in the show notes and that's it for the episode.

[01:01:46] If you have any thoughts about this episode, feel free to send us an email. I'm greg@businesstrip.fm. Matias is matias@businesstrip.fm. You can tweet at us or find us on Instagram @businesstripfm. We'd love to hear from you. This is Business Trip, a podcast about psychedelic entrepreneurship. If you liked this episode, you can help us by subscribing to the podcast and leaving a review.

[01:02:13] I'm your host, Greg Kubin. Business Trip is created by me and Matias Serebrinsky. Producer and editor is Jonathan Davis. Sound design and engineering came from Zack Frank. Our theme music is by Dorian Love and additional music credits are in the show notes. This is Business Trip. Thanks for tripping with us.

[01:02:32] We'll see you next time.

[01:02:43] Matias Serebrinsky: Greg let's talk business 

[01:02:47] Greg Kubin: and now ketamine, but psilocybin 

[01:02:52] Matias Serebrinsky: on psychedelics 

[01:02:55] Genesee Herzberg: psychedelics, 

[01:02:59] Greg Kubin: all humans have like shadows, shadow, shadow, shadow. What's your life's purpose 

[01:03:07] Genesee Herzberg: purpose.

[01:03:13] Greg Kubin: I'm just like blabbering. It's not actually can be a clear purpose. 

[01:03:21] Matias Serebrinsky: Let's talk. .