Daily Schedule: Assertive Community Treatment.

A sam­ple agenda as the con­sult­ing psy­chi­a­trist with an assertive com­mu­nity treat­ment (ACT) team:

7:55am. No one is at the office yet. Insert a key into the gate in front of the build­ing. The gate makes grat­ing and squeak­ing sounds as it rolls up. After enter­ing the build­ing, quickly dis­able the alarm, lock the door on the way in, and roll the gate back down. From the med­ica­tion room, pack into a brown paper bag a pair of gloves, two alco­hol pads, one band-aid, a pinch of 2x2 gauzes, a portable sharps dis­posal con­tainer, and a pocket-sized bot­tle of hand san­i­tizer. Unlock a dif­fer­ent cab­i­net and fish out a small box that con­tains liq­uid haloperi­dol decanoate, a long-acting antipsy­chotic med­ica­tion. Drop that into the brown paper bag.

Leave the office, secure the build­ing, and make sure that the gate is rolled com­pletely down before walk­ing away.

8:40am. Arrive at a patient’s1 apart­ment uptown. She lives with her mother, grand­mother, and her mother’s boyfriend. As usual, she’s still sleep­ing, even though she knew that this visit would occur around 8:45am. She’s wear­ing a strappy tank top and baggy pajama pants. She rubs the sleep form her eyes. She walks back into her bed­room. An elec­tronic rose is in the cor­ner next to her mir­ror. Dif­fer­ent col­ored lip­sticks are on the table. There is a desk lamp on the night­stand, as well as sev­eral magazines.

She shrugs her shoul­ders after real­iz­ing that her offer of a seat on the unmade bed was politely declined. She’s doing pretty well: She’s re-enrolled in GED classes and is study­ing to take the test, though she’s find­ing the math por­tions dif­fi­cult. She’s still going to the local bar on week­ends, but denies get­ting drunk. When she also denies smok­ing mar­i­juana, her response seems hon­est, though her next visit to the office will include a urine drug screen test. The antipsy­chotic med­ica­tion isn’t caus­ing side effects. She asks for advice on how to avoid bad boyfriends.

9:30am. Arrive at the sec­ond patient’s apart­ment after a sub­way ride fur­ther uptown. He lives with his elderly par­ents. He’s not doing well. He yells at his mother and his father often locks him­self in the bed­room so they don’t have to interact.

He begins to share that he is dat­ing a woman, then sud­denly com­ments that he hasn’t drank any alco­hol in months. His mother inter­jects and says that he has come home very late at night smelling of alco­hol. The sto­ries from the past week spill from her mouth; she’s watched him cross and re-cross the same street for two con­sec­u­tive hours. Some­times he yells about the gods who have failed him. Small items—vases, salt and pep­per shak­ers, silverware—have started to go miss­ing from the apartment.

He says he’s tak­ing his med­ica­tions, but his mother says that she finds pills in the trash cans. He mum­bles under his breath.

No, she hasn’t had to nor wanted to call the police. No, he doesn’t want to go to the hos­pi­tal. He’s eat­ing the ham and cheese sand­wich that she’s made for him. She asks what will hap­pen next.

If you feel unsafe, call 911 and call the ACT team. Don’t wait. Just call. We’re all wor­ried about him.”

He rolls his eyes and asks the wall why any­one would think he would hurt any­one. He doesn’t seem to remem­ber that the last time he devel­oped symp­toms and drank alco­hol, he punched his daughter.

10:40am. Arrive at the third patient’s apart­ment after a bus ride across town. He’s an elderly man who believes that his neigh­bors have stolen his inter­nal organs and that can­ni­bals will eat him if he leaves the build­ing. These beliefs as well as gait prob­lems keep him in his apart­ment. This is the per­son who will receive the haloperi­dol injec­tion.

The usual con­ver­sa­tion about his med­ica­tion ensues. He’s will­ing to accept the med­ica­tion, but wants to dis­cuss again why it is at its cur­rent dose. The rea­sons haven’t changed from last month. He nods in what seems to be under­stand­ing, though then asks, “The med­ica­tion will not make my skin turn blue, right?”

This is a sig­nif­i­cant improve­ment from a year ago.

Three large cock­roaches skit­ter across the coun­ter­top. Two empty car­tons of orange juice sit on the kitchen table. He looks into the liv­ing room, which holds his bed. He doesn’t go into the bed­room any­more. He still cries when he thinks about his dead wife.

He rolls up his sleeve and looks at his arm when he receives the injection.

It never hurts when you do it.” He’s prob­a­bly just being nice.

11:45am. Arrive back at the office. A patient sits on the curb, smok­ing a cig­a­rette, while chat­ting up a cab dri­ver. Every­one says hello to each other.

11:50am. Two of the social work­ers are in the office. They and the sec­re­tary all share events from the morn­ing. One of the ACT patients may leave the hos­pi­tal tomor­row. One of the social work­ers will escort him directly from the hos­pi­tal back to the apart­ment if the hos­pi­tal dis­charges the patient.

I’ll visit your guy tomor­row morn­ing,” the other social worker says, refer­ring to the sec­ond patient who lives with his elderly par­ents. “We’ll check in with him every day this week.”

12:00pm. Work on doc­u­men­ta­tion from the morn­ing vis­its. Mind­lessly eat lunch.

12:53pm. Fourth patient arrives for his 1pm appoint­ment. He greets every­one with a warm smile.

He recently started vol­un­teer­ing at the library and teaches young chil­dren how to read. He rides his bicy­cle around Cen­tral Park to help keep his blood sug­ars under bet­ter con­trol. His daugh­ter is com­ing to visit for the hol­i­day. He plans to cook salmon for din­ner tonight. He’d rather have fried chicken.

I’m scared to lower my med­ica­tion, Doc,” he says. “I don’t want to end up at the hos­pi­tal again. But if you think all this weight gain might be from the med­i­cine, I guess we could try it—you said real slow, right?”

After some more dis­cus­sion, he con­cludes, “No, let’s not change the med­i­cine now. Lemme get through the hol­i­days and then we’ll try. Real slow. Real slow.”

His wishes are hon­ored with­out argument.

2:00pm. The fifth patient hasn’t arrived.

2:10pm. The fifth patient still hasn’t arrived. She’s more orga­nized than peo­ple might ini­tially believe, but she’s rarely punctual.

2:17pm. “Heya doc, how you doing, how you doing,” the fifth patient says, flop­ping down on the seat. She’s chew­ing on a pop­si­cle stick. She’s tied the two ends of a neck­tie together and is wear­ing that around her neck like a neck­lace. Four other neck­ties are tied around her neck the same way. Ear phones cover her ears, but they’re not plugged into any­thing. Her striped socks are pulled over her baggy sweatpants.

Heya doc, how you doing, how you doing, the vapor’s hot today, so hot. The ici­cles bring down the vapor, the vapor pulls the mag­net and the poles spin, they spin, that’s what makes the Earth spin, the vapor around the Earth spins, too, spins like a record, so cool, so cool….”

She just fin­ished her first week as the fil­ing clerk for the drop-in cen­ter. The staff there said that she did good work and that she seems to like it, but she occa­sion­ally breaks out into song.

Do you like your new job?”

Yes, yes, but I want them to like my new job, too. I like the money, too, I can buy myself some new shoes, new blue shoes, new blue frue true krue shoes, so krue, so cruel, cruel world.”

On the way out, she flings the pop­si­cle stick into the trash­can and belts out, “NEW YOOOOORKCONCRETE JUNGLES WHERE DREAMS ARE MADE OF….”

3:05pm. Sixth patient arrives. He sits down and looks out the office win­dow into the lobby. Every­one said hi to him as he walked in. He didn’t respond.

He doesn’t say any­thing in the room. He doesn’t make any eye con­tact. He exam­ines his nails. He reties his shoelaces. He rolls up his pant legs. He strokes his beard. He fishes a half-smoked cig­a­rette out of his pocket, then puts it back in.

What’s going on? Is some­thing wrong?”

He sighs and shakes his head. He gets up and doesn’t look up in acknowl­edg­ment when he hears entreaties to stay. As he walks out of the office, he finally says, “I’ll be back.”

3:20pm. Ask one of the social work­ers to fol­low the Tacit Man out of the build­ing with hopes that they will have a conversation.

3:22pm. Watch from the lobby while the social worker and the Tacit Man talk. They’re actu­ally speak­ing to each other.

3:25pm. The social worker walks back into the build­ing and the Tacit Man walks across the street.

Tacit Man is fine, just hav­ing a bad day,” the social worker says. “He’ll come back tomor­row to see you, same time.”

Thank you!”

3:27pm. Call patients to remind them of meet­ings sched­uled for tomor­row. Most of them answer their phones.

3:45pm. Resume doc­u­men­ta­tion with occa­sional inter­rup­tions from other patients wan­der­ing into the office to say hello.

4:35pm. Coor­di­nate plans with the social work­ers for tomor­row. Dis­cuss med­ica­tion changes, med­ica­tion deliv­er­ies, and which patients need closer monitoring.

4:45pm. Leave the office. That same client who was sit­ting on the curb and smok­ing is still sit­ting on the curb and smok­ing. He waves hello. I wave back.

  1. All patients described here are com­pos­ites of peo­ple I have seen across time.