Welcome to the Reality Check podcast. Psychosis is Real, so is Recovery.

On this episode, Serena Chaudhry speaks with the CEO and President of The APT Foundation.

Join us as we dive into Breaking Barriers to Care and smashing stigma. Serena and Lynn reflect on the stark similarities faced within both of their fields and how both ultimately affect patient outcomes. Forget everything you thought you knew about models of care and take a listen to this fascinating episode.

For more information about Clear Answers to Louisiana Mental Health (CALM) and their Early Intervention Psychosis Program (EPIC NOLA), visit the website: www.calmnola.org

Find out more about The APT Foundation here: www.aptfoundation.org

Podcast produced by Red Rock Branding – www.redrockbranding.com

Serena: Welcome to the Reality Check. Psychosis is real. So is Recovery podcast.

Ashley: I'm Dr. Ashley Weiss. I'm a child adolescent psychiatrist. And I'm Serena Chaudhry. I'm a clinical social worker, and we are the co-founders of Epic nola, which is the Early Psychosis Intervention Clinic in New Orleans, and also the co-founders of Calm, Clear Answers to Louisiana Mental Health.

Serena: Good afternoon and welcome to Reality Check. I'm so excited to have Lynn Madden from the APT Foundation here with us today. Lynn, welcome to Reality Check.

Lynn Madden: Thank you, Serena. It's a real pleasure to be here. All

Serena: right, we're gonna get down to it after some technological challenges connecting. So for listeners who do not know you or apt, can you tell us a little bit about yourself and how you gotta this point and the incredible work that APT does?

Lynn Madden: To deliver treatment to people with substance use disorders. So back in 1970, that was relatively unheard of and certainly not medical treatment, if you will. Which has been part of the foundation history since 1970. So this year we're 55 years old. We have around 7,500 patients. Our programs program across six locations and we are pretty well known for substance use treatment services, particularly treatment services that involve methadone or buprenorphine, so medications for opioid use disorder, but we also provide primary care here, psychiatry services, vocational services.

Lynn Madden: We have a residential treatment program, so we're really a, a comprehensive treatment set of treatment services for people. Health and challenges.

Serena: To help people better understand why this work is necessary and understand how you all are doing it. So my, can you tell me more about open access and how that fits into the APT model?

Lynn Madden: I was recruited here because the organization was really struggling. Both in terms of census and in terms of finances. And I had recently at that time become a huge and passionate fan of what I call open access to treatment. And what that means to me is that when you decide that you want to enter treatment, we need to be here for you.

Lynn Madden: So we created through a series of what we call change projects, we engineered our system to respond to people in real time. So today you can walk into APT Foundation six days a week regardless of your ability to pay. You'll be seen by licensed providers, and you'll be prescribed a medicine, a treatment.

Lynn Madden: You'll be offered something that suits your circumstance and that you actually want. So it's kind of a, it's kind of a triangle. Services that people will come to that we can afford to deliver and that they wanna come to. Right. So it's a better effective, so it's a, that triangle is really important, I think.

Lynn Madden: And we, we accept everyone. If we prescribe you a medicine, you will receive the medicine that day. So the biggest barrier to treatment with, for opioid use disorder in the United States. Which has the highest number of opioid disorder persons in the world. The biggest barrier to treatment is actually waiting time.

Lynn Madden: Right? So if you think about, you know what, what do we know about substance use disorders? I mean, one of the things we know is that. If you have a substance use issue, part of what you're struggling with is frontal lobe. The front part. Mm-hmm. Being compromised, right? So frontal lobe compromise, what does that mean?

Lynn Madden: It means my motivation is limited or non-existent. It means my executive functioning or organizational skills aren't very good. It makes me forgetful, it makes me impulsive, all of those kinds of things. So we have this whole set of illnesses, substance use issues, and mental health issues for that matter, that we force a lot of people through a complicated process to get admitted to, when in fact they're not in a good place to manage complex processes, like come three weeks from next Tuesday, bring these five pieces of paper and show up on time or 15 minutes early.

Lynn Madden: That's a really hard road for people to navigate.

Serena: Absolutely. And it's so similar to the challenges that our patients have upon Right. Coming to our first episode psychosis clinic. So I wanna back up a second because you said many things that got me excited. The first one is the open access. Six days a week people come in, get meds the same day, and you accept anyone.

Serena: Yeah. Help me understand both of those big points. How do you accept everyone? How do you get meds to people the same day?

Lynn Madden: Yeah. So that, those are both excellent questions. So we accept everyone because we've created a system that is stripped down to essentials. If you don't make appointments, you don't need all those people at the front door making appointments, that isn't a job anymore.

Lynn Madden: Instead, that person can in fact help you figure out if you're eligible for some kind of insurance benefit or help you get a bus pass so you can get to treatment. So we repurposed a lot of our staff away from the more traditional approaches like appointment making so that they became more supportive in the process of helping prospective patients really be successful.

Lynn Madden: The other thing about being able to afford it is that if you can't pay today, doesn't mean you'll never be able to pay. It means is you need to get better enough to get organized in your life so that you can figure out what your primary means of support might be. So we just take all commerce. We have a very efficient system.

Lynn Madden: We have a lot of group therapy. That’s available for people. And if there are 12 people in the chairs in group, or 11 people in the chairs in group, it doesn't make that much difference, right? In terms of how much revenue actually comes through the door. So this idea that appointments are tied to billing that are tied to certain providers and that have to be carefully organized is actually super inefficient.

Serena: It is so inefficient and you've just blown my mind. I really. So many of the challenges that we face in providing good care for people are complicated by the system in which we work and try to provide the treatment. Yes, and you have just dismantled the system and created a system, not just you historically have done this and are getting people the treatment they need efficiently.

Lynn Madden: Yes. And you know, not, not for nothing. It turns out that the people who need treatment actually contribute to their own care. If they get stable enough, which they need, in this case medication for, or a place to go all day long, when it's freezing outside, you know, all of the things that they may not have access to.

Lynn Madden: Once they become stable, they help other patients. They become employed. They start managing their own home lives. Many of them go back to school or become professionals of one kind or another. So this idea that you're really stuck at a certain place in your life because you have a substance use disorder.

Lynn Madden: Or that you are not valuable and useful is also at the heart of this set of ideas of open access, right? We care. Healthcare is a verb. To care about people is really important, and you have to, you have to show that with the system that you create.

Serena: Well, absolutely because if someone is brave enough, has enough insight and is brave enough to walk through the door to ask for help and ask for treatment, why would we not give it to them?

Serena: Then why do we create more barriers to get them what they want and what they need?

Lynn Madden: Yeah, and the urgency. The lack of urgency, I guess I would say the urgency with which we treat substance use disorders. Is not satisfactory to me. Every time you use drugs, you could die. Yes. Every time that's an emergency.

Lynn Madden: We can't say come in a month. Right, and then pretend that that's some kind of motivational test.

Serena: Right, and I think you so accurately and eloquently described why people can't come back in a month. It's not for a lack of desire. It's not for a lack of interest in a commitment to getting better.

Serena: It's literally the illness that they are managing, getting in the way of them getting the help that they came initially and told you that they wanted.

Lynn Madden: Yes. So there's a different, so instead of motivational testing. Let's talk about capitalizing on motivation.

Serena: Yes, you're empowering people from the moment they walk in because you're giving them what they ask,

Lynn Madden: and they want something right now.

Lynn Madden: That's why they came. And so why don't we ask them, what, what can I do for you? What do you want? What do you need? Let's try this medication and let's start today. And the guess what, you're gonna feel better this afternoon. If you start taking this medicine today, you're not gonna feel great, but you're gonna feel better than you do right this minute.

Lynn Madden: And tomorrow you're gonna feel even better than that. And so you can really reinforce the clinical effectiveness of these medications by helping people access them in real time.

Serena: Absolutely. So how does the APT Foundation support this? 'cause? This is a, how do you lift least seemingly from the outside

Lynn Madden: the way support.

Lynn Madden: Follow all the rules and regulations, right? Mm-hmm. But people made them up. We made them up. Culturally, and we can unmake some of them or advocate for some of them to be unmade. So one example I'll give you is outpatient therapy. If you get permission from an insurance company to deliver outpatient therapy, it's usually something like one time per week for.

Lynn Madden: Two months or something like that. An arbitrary

Serena: number,

Lynn Madden: right? We've advocated for people to come to as many groups as they wanna come to. Come and see your clinician or your counselor as often as you want. You're welcome. Here, I have a person, I was just talking to one of my program directors this week.

Lynn Madden: She said, we opened up our group schedule a little more and one guy came last Friday, he went to five groups. He's only required to go to one group. So part of the ways of supporting this is to understand the regulations, make sure the people that we call patients know what the regulations are.

Lynn Madden: So I tell them, look, you have to come at least once a month. But you can come as much as you want to. And then again, without appointment making, everybody who works here is busy all day long, but they're not, they don't have a, they don't have a caseload. Right where share everyone shares a caseload.

Lynn Madden: Staff share the caseload. So if Serena's not here today, and I have a real question mm-hmm. I might go down the hall and I'm gonna go to Jill's office. Mm-hmm. Right? Because I kind of like Jill and I met her and she smiled at me in the hallway. So what we've learned is that people create their own treatment teams.

Lynn Madden: So we don't have any of that. We don't spend any time like treatment matching and all of that. Right, right, right. We don't do any of those things. So when you, when I say strip down the model, we literally make ourselves present, or our teams make themselves mm-hmm. For the patients in real time. And we post on a board, what groups are available today, who's off today?

Lynn Madden: So you come in and you do what you wanna do, but you have to do the minimum. That is a la that is required for us to bill your services if you have an insurance. Mm-hmm. And if you don't have an insurance, well someday when you start to feel better, we'll help you figure out how to get one. Or not.

Serena: Wow. So this is, so I, I get excited about our wraparound services that we provide for our. Who come to EPIC and the fact that we are really coordinated specialty care in a very authentic way. We work collaboratively together to support young people and their families. But what you're describing to me is next level because it, it, it is like wraparound and a hug and just like something happening all the time.

Serena: That is amazing.

Lynn Madden: And it's about, for me, it's about empowering, as you said. Also, I think about other kind of like social psychology ideas. You know, I think that one of the things that giving people options and choices mm-hmm. Does, is that it repairs self-efficacy. Of course. See, I'm not, I can't prove that per se, although someday I'm gonna figure out how to do that.

Lynn Madden: But really, I think, you know, treating people as if they're autonomous mm-hmm. In situ healthcare settings where they have been. Literally controlled right

Serena: and told what to do and where to go

Lynn Madden: and when to do it, and who to do it with and what they can't do because they're gonna lose what they're allowed to do.

Lynn Madden: I mean, there's a lot of restrictions on people in the mental health and substance use space that don't seem to be effective. And so when you think about that, like why do you have to make an appointment for someone, even if that person is being prescribed a medicine, some kind of, you know, psychoactive medication or psychotropic medication, just tell them, come back the third week of the month.

Lynn Madden: You don't have to say, come back on Tuesday at 10 o'clock in the morning. Right, right. Because coming back the third week of the month gives them options. It's much easier to manage when they start thinking about it, right? It's much easier to manage and you don't make mistakes, and so when you don't make mistakes, now you start to feel better about yourself.

Lynn Madden: Your treatment team is feeling better about you mean all of those things.

Serena: Absolutely. And the treatment team also is feeling better about themselves 'cause they're seeing people right and not getting frustrated about people not showing up to appointments that they are hard for them to remember or manage.

Serena: Exactly. Has APT always operated this way, or is this, this is under the work that you've been doing? Yeah, this is what we

Lynn Madden: Awesome, awesome staff. And we just one step at a time. Mm-hmm. We identified and eliminated barriers to treatment entries. Mm-hmm. What we were trying to do is something that we knew. Was a barrier, barrier. IE waiting time, we were trying to reduce waiting time. That's all we set out to do. Right. So you can make this really simple for staffs and team members, and I now do this as a coach and a researcher in various settings around mm-hmm.

Lynn Madden: Tomorrow. But really what we set out to do is say, okay, what, what is our waiting time? Mm-hmm. Was 22 days. Yeah. Not, not okay. After we already met you, so I don't know how long you waited, right? It was 22 days after we met you, before you received a medicine for an opioid use disorder. 22 days. I said, okay, yeah.

Lynn Madden: What are we doing here? So we walked through the process, right? And we discovered all kinds of things that we were doing that we didn't have to do. That we systematically changed or eliminated and we just kept measuring, waiting, time measure, waiting time, measure, waiting time. So we didn't start out by waking up one day and saying, okay, tomorrow it's all walk-in.

Lynn Madden: We started out doing things like, let's schedule a physical and the psychiatric evaluation on the same day so people don't have to come back twice. Right. You know, things like, like that. And every organization has these kinds of things. Right, right. And you can find them and there are techniques for finding them.

Lynn Madden: So we, we found as many as we could. And then ultimately we said, okay, we're gonna open up access to treatment and just see whoever walks in and commit ourselves. Finishing the eval the same day and sitting with the person and creating a plan. Amazing. So then we started doing that and then we said, Hey, let's deliver medicine the same day we can do this.

Lynn Madden: So that was a matter of scheduling, breaking down kind of Prescribers are trained to appointment making.

Serena: Yeah. Right. I think it's, it's questioning the, questioning the model. We, and I will admit this, and myself can complain in and out about the models in which we work and how they don't work for us. But questioning it and changing it is really where, right?

Serena: Yeah. Is what you all have done and are having success in doing. So I wanna talk, you're talking a lot about barriers to care and how you're breaking them down internally. Is hugely important because we can look externally to what the barriers are to get for someone to get to the door, but then there continue to be barriers once they're there.

Serena: One of the barriers both inside and out is stigma. So I wanna talk about stigma and how stigma plays a role in people getting to the APT Foundation and or staying at the APT Foundation.

Lynn Madden: Yeah, stigma plays a huge role in all. Aspects of mental health care and substance use disorders, perhaps even more so, although it's hard to know depending on what set of issues and illnesses or symptoms you might be talking about.

Lynn Madden: But people with substance use disorders, I like to talk about stigma as both internal and Yeah, absolutely. They believe that they're not good people. Right. And the system in general reinforces that. Absolutely. So when you say you have to wait a month for your appointment, which is the average waiting time in the United States for an evaluation for a substance use disorder, what are we saying?

Lynn Madden: What we're saying is you're not worth very much. Right. What's going on with you is not important. Right. That's stigmatizing. When we say things like Methadone treatment is the medication of last resort, or. Using buprenorphine or medicine for opioid use disorder to treat your opioid disorder means you're still addicted to medicines.

Lynn Madden: Right? So we have a lot of ways in which we actualize stigma. But stigma actually kills people. Yes. Because they're secrets, right? They keep, they don't tell anyone about what's going on with them. You know, a 17-year-old doesn't tell their parents because they don't wanna be judged. They've heard their parents talking.

Lynn Madden: Yet we still talk about things like. Let's discontinue Naloxone distribution. Right. Let's discontinue harm reduction programs. That's in some of our recent funding. Yes. It's happening through Congress in New Orleans now. Right. So these are, these stigmas are, structural systems are set up in ways that are difficult for people and reinforce that they should feel bad about themselves and that they're not important and they're also social.

Lynn Madden: Yes. You're considered a spoiled person. Back to social psychology here for a bit. Right? You have a spoiled identity if you have a drug use disorder, if you have schizophrenia. You are a person who's not any longer worthy. Right. You become identified by your diagnosis. Instead of being identified as an individual person with agency and other.

Lynn Madden: Of their own lives.

Serena: Yeah, absolutely. And I, right, this stigma plays out in very similar ways for the work you do and the work that we do. And I appreciate the recognition that it's internal and external. And we was just on the last interview I did with Kody Green, who's someone with lived experience, he, he was able to right, articulate that and talk about how that's been true for himself.

Serena: So what are you doing with the APT Foundation to address stigma?

Lynn Madden: Yeah, so the first thing to foster, yeah, that's what we need to do. We totally need to do that because people are dying and they're us. There

Serena: are, the numbers are staggering and the numbers of people who can survive if we just stop. And look upstream.

Serena: Yes. Change the way we talk about things and intervene early.

Lynn Madden: Fewer than 12% of people living with an opioid use disorder are in treatment. That means 88% are not, and part of it is there's no access to medicine, depending on where you live. Medicine is the gold standard for opioid use disorder and barely anything else works.

Lynn Madden: Although people would love to debate that point. The, the data is pretty solid, right? The, the real issue here is structural access to care. You have physicians, entire communities that say, oh, we don't see those people. I don't prescribe that medicine. So what we're trying to do is destigmatize the medication itself in many ways, kind of publicly using let's Break Barriers to Treatment campaign.

Lynn Madden: Interviews like this, billboards ads on the bus, you know? These are our regular people and they really do and can get better. But they have to walk through that door and they have to be encouraged to walk through the door door. So we're trying to create better access, not only here at apt, but among our peers across the country and across the world.

Lynn Madden: We're trying to demystify and destigmatize the medicines. Nothing else works, right? I mean, so we can talk about. You who don't wanna take an antibiotic or whatever, but if you, if you have a condition right, that's only amenable to an antibiotic, you have to take an antibiotic. Yes. And you're not gonna get better.

Lynn Madden: Right. This is the same thing. Yeah. Fewer than 10% of people enter a one year period of non-opioid use without the use of a medicine that is more than 10% staggering. It's staggering. And there's seven and a half million of them. Right. I mean, so this is a public health emergency? Yes. That we don't treat with that kind of urgency.

Lynn Madden: We talk about it like the opioid crisis, but if you really think about what we're doing, it's, it's not urgent enough. From my perspective.

Serena: No, it's not urgent enough. And the urgency is there in the work that we do to young people are ill, and the longer they stay untreated and undiagnosed with a psychotic disorder, the worse their prognostic outcomes that.

Serena: But we need to reduce stigma. We need to get people talking about what the symptoms are educated about, what the symptoms are. So we are doing similar things with bus ads, billboards campaigns that attempt to de-stigmatize, and we've seen some promising results and had had very positive responses in and around New Orleans and Louisiana.

Serena: I'm curious what the responses have been in the New Haven area and beyond.

Lynn Madden: Yeah, I would say they're mixed. We have really good social media response, so we know we have a lot more people looking at our website, engaging with us on Facebook, for example, or Instagram. We just started a TikTok situation I hear.

Lynn Madden: Nice. I haven't quite tuned into that yet, but the numbers look really good. So engagement is good in terms of, you know, community leaders in various communities that we work in, I haven't seen a lot of shifting. In their minds, their, I work, of course, in this organization, but I also have the opportunity to interact with medical students and fellows and residents.

Lynn Madden: And I talk about this and it's surprising to me how many people still don't well, grounded and diagnosing and treating opioid disorders right as they, as they try to move through medical education. So that's another space that we're really trying to work in.

Serena: Absolutely. I totally agree. And we're there with you, I think medical schools, I think schools of social work. You know, you have 70 some percent of social workers are on the front lines of diagnosing and or helping people to get treatment.

Serena: Yes. Yet there are is not enough training and specialized education around these serious conditions, these emergencies, these public health emergencies at that level. So we have to start wrapping up, but I wanted to take the last few moments to ask you where you think the next steps are. Where are the next big steps in making changes for the APT Foundation?

Lynn Madden: Yeah, I mean, I think at APT Foundation, some of the things that we're doing, you really touched upon. We are trying very hard to work in the medical education and clinical education spaces. We're really trying to work in public spaces with groups of interested people. So I think that that work is very important and elevating the voices of people with lived experience to have a seat at the table when it comes to policy making.

Lynn Madden: And so one thought I have that I would love to share with you is that one of the ways that we measured the, the efficacy, if you will, of substance use treatment is by length of stay. But the reality is that everyone who has a substance use disorder has a chronic issue and they virtually all return to drug use at one point or another.

Lynn Madden: In fact, the average person is five to seven times before you, this one year period of non-op. We should tell people that. So I'm working on shared decision making with patients saying things in our organization, myself and others here at APT Foundation, who publish a lot in peer reviewed journals saying, hey, you know, you really can help people.

Lynn Madden: Hey, guess what? They do really well when they enter, you know? So just getting the word out in that space. Is, is really, really important as well. So those are some of the, I, I think of as the real frontiers. Right. So it's not just the establishment, if you will, it's community based as well.

Lynn Madden: So that kind of structural, social set of issues. And then the third issue, the third set of issues is around. Criminalizing behaviors, right? So when we criminalize people and we incarcerate them, we put them under some form of community supervision or control. We're essentially playing out our policies on their lives.

Lynn Madden: And if they don't have access to treatment, let's just. Set aside for a moment that maybe a lot of these people should never go to jail or prison in the first place. If they do, they need access to good, effective healthcare and they need to, that access needs to follow them into the rest of their lives after they're released.

Serena: Absolutely. And they needed immediately, they shouldn't be incarcerated because they need help because they have a medical condition. And if they are incarcerated, they need that care and it needs to follow them well. I think this is where we as a society, fall short with these chronic illnesses. Yes, we can, in some instances try and provide really good care, really good care, and help people.

Serena: Launch, give them autonomy, set them on their path of recovery, and we need to sustain them on that path. We can't just let them go. We need to, as a community, as clinics, as providers, and as a community, help support people because a chronic illness is chronic, like relapse may occur in the instance of a psychotic disorder, one will likely get ill again.

Serena: One may end up in the hospital again. That is the nature of the illness. Yeah. And we are shortsighted to think that a short treatment and or just treating people in the moment is gonna make long-term outcomes.

Lynn Madden: We wouldn’t do it for anyone else. You know? Now a person living with diabetes, you know, and they don't control their glucose levels, very common.

Lynn Madden: They are not disenfranchised from the healthcare system. As a result, we don't say, oh, you must not be committed to this, or You are not ready for this, or, I'm not gonna treat you in the emergency department. You know, we don't say any of those things even though they have a long term chronic condition that can be affected by their behavior, right?

Lynn Madden: Mm-hmm. We don't them quote accountable. Which is a word I dislike very much. You don't hold them accountable for the manifestation of their illness. Exactly.

Serena: We're stigmatizing people, right? They're stigmatized when they come in, they're stigmatized when they leave, and those are, you know, that has to stop.

Lynn Madden: Yes, absolutely. Yeah.

Serena: And maybe that's where we stop. Thank you so much for the amazing work you're doing. I am so inspired and I need to talk to you off of this podcast because I would love to do that. You're doing things that I want us to do at EPIC. Thank you Lynn Madden for joining us on Reality Check.

Lynn Madden: Thank you so much, Serena. It's my pleasure. Take care.

Serena: Until next time, thanks for taking the time to get your reality check. And remember, psychosis is real, so is recovery.

Ashley: If you have enjoyed this episode or found it useful, please subscribe wherever you get your podcast from. And check out the website calm nola.org.