Reflections on a Decade of Assertive Community Treatment

Those wild pigs, snorting and roaring around my urban backyard, are terrifying me so I call the police to complain. Again. They duly come by but again I say I’m fine; I must have phoned them in error.

Later, I’m at the hospital with my terrified mother. The staff again refuse to treat me. A psychiatrist tells my mother to stop enabling me by bringing me to the emergency department.

Back at home, my apartment grows increasingly chaotic. I’ve thrown my books, papers and photographs out onto the back lawn. I’ve upended my fridge and sprayed flour all over my living space. I’m rambling incoherently all over the internet, alarming and alienating my friends. Madness is taking over my life.

I need more alcohol to put out the flames, and stumble up to the pub. The need for nicotine becomes overwhelming so I crouch down by the fireplace, light up a cigarette and blow the smoke up the chimney. I’m firmly told not to do that and so move on to emptying the salt and pepper shakers. I go next to Starbucks and stuff their toilet with newspaper.

Eventually, the police put me out of my misery and I am charged with several criminal offences. Inexplicably, my pro bono lawyer is willing to accept my instructions and the Court accepts my guilty plea. No wrongdoing is found on the part of my lawyer, just six months out of law school, with no qualms whatsoever about representing the floridly psychotic. Legally, he should have recognized that I was neither competent to retain counsel nor able to stand trial and should have been deemed “not criminally responsible” for my crimes.

One of the terms of my sentence was that I was to be subjected to “assertive” community treatment (ACT). That was almost ten years ago and there is no end in sight. I consider a decade of ACT to be more than fair penance for my 2010 crimes, and I am completely fed up with the psychiatric system and long to be released.

By the time I was introduced to ACT, my mania had already subsided and I suffered a terrible depression from the latter part of 2010 to the end of 2012. For most of that time, all psychiatry offered me was ECT and Risperdal injections, so it’s not surprising that the wait for recovery was a long one. Although I had rented an apartment, I was not up to living on my own and spent the time practically comatose in my parents’ basement. I was underweight and completely dysfunctional. I spent about 20 hours a day in bed and if I was able to have a shower, then that would count as a good week. I didn’t have the energy to commit suicide.

However, I recovered as I always eventually do and did well without psychiatric interference through 2013 and most of 2014. I moved into my apartment, took some university courses, volunteered and worked part-time. Sadly, towards the end of 2014, mania reared its ugly head again and I was re-hospitalized. My stay on the psych ward was brutal (21 consecutive days in seclusion) but if I had stayed on the oft-recommended “meds for life” program, I likely never would have experienced anything like that glorious unmedicated stretch.

Whenever I am released from one of my countless sojourns in hospital, I am put on “Extended Leave” — that is, into the care of an ACT (Assertive Community Treatment) Team. In some respects, ACT is a worse fate than being in hospital, where there is solidarity and patients help each other. When you’re inside, you only have one problem: how to get out. When you’re out, you have to deal with ACT, which leads to a host of other problems. ACT members tend to be intrusive and authoritarian. It’s chilling to know that anything I do or say will be judged and duly noted in my chart. There is little incentive to tell the truth, as the very real possibility of a mental-health “apprehension” is always present.

At its best, ACT has offered me real help: locating housing for me, no mean feat with a criminal record and eviction under my belt. In the main, though, ACT has been disempowering, fostering learned helplessness and dependence through, among other things, harmful counselling (“You’re never well. You’re only more ill or less ill.”) and the endless repetition of mainstream psychiatric dogma. ACT operates solely on the medical model of mental illness: the overriding goal is medication compliance through coercion, whether overt or subtle.

My relationship with my ACT team has not been a happy one. In December of 2017, I missed an appointment with my psychiatrist. That night, I was arrested and taken to the hospital by the Victoria City Police. The hospital psychiatrist noted that I was “irritable” and had missed an appointment with my doctor. I pleaded guilty to the latter, but as to the former, I’m not sure exactly what is the “right” emotion to exhibit when one is dragged out of the safety of one’s home for no reason by the police. My justified anger was pathologized, and I was hauled off to the seclusion room by security goons.

I’ve been struggling with episodic madness for twenty years and have gained sufficient insight to know when I’m in trouble and when I can benefit from pharmacological assistance. The only way to get that assistance, however, is through our dysfunctional mental health system — and therein lies the problem. A psychiatrist can take away my freedom with the stroke of a pen. I could question his or her assumptions (“patient is argumentative”), reject neuroleptics (“patient is noncompliant”), point out the dynamics of the inherent power imbalance between us (“patient is incoherent”), or, most dangerously, express anger (“patient requires hospital care”).

Sometimes I am crazy and sometimes I need help, but that help must not be forced upon me. I need to direct my own care; I need to be listened to. My madness is episodic, so thoughtful analysis of triggers could produce valuable information to help maintain my mental health. There is not only the rhythm of my moods to consider; there’s also the soul-destroying nature of psychiatric coercion to recover from.

ACT is presented by its proponents as a humane alternative to hospital. In fact, however, most people subjected to ACT, most of the time, are not eligible for hospitalization. This is unfair. Even if we were to accept the premise that involuntary treatment is a reasonable therapeutic practice, the threshold for administering it should surely be the same whether you are an inpatient or an outpatient; i.e., if you aren’t crazy enough to be hospitalized, then assertive community treatment should not be inflicted upon you.

I was recently released from hospital on Extended Leave with the following conditions: Take all medications as prescribed, attend all appointments with psychiatrist and ACT members, and submit to weekly bloodwork. My hospital psychiatrist noted my “bad attitude” toward my ACT team and Extended Leave. Actually, my bad attitude is the only reason I have survived these last nine years, some of which time I suffered what could only be described as psychiatric assault. Having ACT in my life every day is an onerous burden. If I survive this, it will be in spite of psychiatry, not because of it.

I feel that I have no one to blame but myself. I was suffering from depression and made the grave mistake of telling my case manager. I saw the psychiatrist the next day and was immediately put on witnessed meds. In my journal I wrote, “Fuck. What have I done?” and then took a fistful of Ativan and tried to strangle myself with my bathrobe belt. This was seen as evidence of a bipolar “mixed state” and was taken pretty seriously as a suicide attempt, which it was not. It was a cry for help, a dysfunctional response to being trapped again in the psychiatric machine.

I loathed my hospital psychiatrist and our surreal conversations:

“Where did you go on your pass?”

“I went downtown with my mother.”

“What did you do there?”

“We had lunch and then went shopping.”

“Where did you go for lunch?”

“The Dutch Bakery.”

“And where did you go shopping?”

“Monk’s Office Supply.”

“What did you buy there?”

“I bought banker’s boxes and dry erase markers.”

“Why do you need banker’s boxes?”

“One is for my notes and one is for papers to be shredded.”

“Why do you need to shred papers?”

I could go on but I think you get the idea.

This same psychiatrist advised me not to drink coffee, claiming that it was bad for me. I was taking Abilify, Lamotrogine, Ativan, Wellbutrin, olanzapine (since discontinued), loxapine (since discontinued) and clozapine. Somehow, I don’t find myself worrying about the effects of caffeine. For me, liberal amounts of caffeine and nicotine gum are essential to fight the effects of the myriad drugs I am on. I’m thankful my new psychiatrist took me off the olanzapine as it is truly an awful drug, which caused me to gain 35 pounds in just two months.

The clozapine renders me practically immobilized within 20 minutes after taking it. It usually takes three to six hours of sleep to get functional again. Clozapine was presented as the gold standard for antipsychotics, and I mistakenly assumed this meant it was the only antipsychotic I would be taking. No, I am still on the maximum dose of another antipsychotic, long-acting injectible Abilify, as well.

When I left the hospital, I made the decision that members of my ACT team are not allowed into my home. My home is my sanctuary and I don’t want it polluted any further by psychiatry. This raised some eyebrows, but I am adamant on this point. It’s a minor act of resistance but it means the world to me. The conditions of my leave say I have to meet with them; they say nothing about where this will happen.

My diagnosis is fluid; currently I’m “schizoaffective,” but usually I’m “bipolar.” Since all of these labels are completely subjective and arbitrary, I’m not terribly concerned. Also, it really doesn’t matter what your diagnosis is, since their answer to everything is more antipsychotics.

ACT is an effective method of social control and has more to do with saving money than assisting those in need. Money is saved by turning patients’ homes into hospitals. The cavalier attitude towards forced drugging is really quite shocking. My ACT team’s surveillance of me is beyond creepy. I hate being scrutinized and judged. I hate making small talk with strangers who have the authority to have me “recalled” back to hospital. I am back at square one with ACT and am feeling very discouraged.

Luckily, I have a new psychiatrist who seems much more reasonable and respectful than the last two I have been forced to deal with. However, this psychiatrist will be inheriting five volumes of my medical records, much of which are filled with inaccuracies and outright lies. Like many involuntary patients, in a bid for freedom, I tend to say exactly what my doctors want to hear. That’s one of the problems with coercive psychiatry: It’s not a route to the truth, and without truth, there can be no therapeutic relationship. That is the great failing of involuntary treatment whether in hospital or in the community.