Reflections on a Decade of Assertive Community Treatment

Francesca Simpson
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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.

22 COMMENTS

  1. Dear Fransesca, thank you for this article. As you say, there is no truth telling in psychiatry, or for that matter, within all medical circles. It seems to make no difference what you say. No matter what you say, their pencils make the scratches that determine your future. And not only does it affect your future within the system, but it greatly affects YOU, within yourself. It can color not just your external reality but internal as well, because nothing about the system has a human quality. They simply go by what they have been taught, the “distancing from the patient” is always felt and leads to no connection at all. They have been taught that connection is not good for the patient. It ends up being surreal experience. It is funny too how they release you back into the “community”, that word sounding quite warm and communal, yet YOUR community is you having ACT. I do hope that you find others near you to interact with.

  2. Francesca,
    Thank you for sharing. This is such a powerful depiction of how the mental health system twists concepts of “care” into acts of coercion and control. You deserve to feel empowered in your treatment and I hope you have some supportive voices in your life that take your actual needs into consideration. Keep channeling that creative and impassioned voice!

  3. “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.” Good point.

    And when dealing with a completely scientifically fraud based psychiatric industry, who claims ignorance of the fact that the ADHD drugs and antidepressants can create the “bipolar” symptoms, as Whitaker pointed out in “Anatomy of an Epidemic.” And such misdiagnoses used to be pointed out as malpractice in the DSM-IV-TR, but this wisdom was taken out of the DSM5.

    And, as all doctors are taught in med school, the antidepressants and antipsychotics can make a person “psychotic” and “mad as a hatter,” in other words they can create the positive symptoms of “schizophrenia,” via anticholinergic toxidrome. But all psychiatrists lie and deny this reality about their “wonder drugs.” Not to mention the antipsychotics/neuroleptics can also create the negative symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome.

    When everything the psychiatrists claim to believe about the drugs they force onto others is a lie, which it is, so there is no truth being told by the psychiatrists. And this is where we are, everything psychiatry claims is truth, is a lie. We do get to the point “there can be no therapeutic relationship.”

    God bless, Francesca, I wish you the best in escaping the insane and scientific fraud based, completely disingenuous, psychiatric system. As the DSM author, Allen Frances, stated nearly a decade ago, “it’s bullshit.”

  4. Thank you also for sharing, Francesca.

    If you robbed a bank you wouldn’t get 10 years.

    It brings back the misery of “psychiatry” to me. Having to “please” defeats the purpose.

    When I was in my early 20s I was given permission to come off drugs completely, but I couldn’t. I experienced hospitalizations and suicide attempts. But then I discovered that I could cut the medication to a level that didn’t disable me (and get back to life).

    Thanks again, you’re writing is very sharp!

  5. Hey Francesca, you write

    “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.”

    On the sworn testimony of a Community Nurse (your friendly ACT team) I was told I was to be snatched from my bed and transported against my will to a locked ward for …. wait for it, being “agitated and pacing”. Now let me say this I was surrounded at the time this “observation” was made and in no position to be pacing. I was joking with the Community Nurse until he told me I was being dragged off by police in front of my in laws so how agitated could I have been? (and he tells me in his sworn testimony that I had “potential for damage to reputation and meaningful relationships”? Does he not recognise the stink he spreads everywhere he goes? His ‘verballing’ technique means that everyone he comes across has a mental illness and is going to be hauled of for examination. A 100% record using this corrupt practice. Not to mention the damage he does to reputations and meaningful relationships). So my response to being detained is used as justification for detaining me. They teach flipping the script in Medical School? And these people are trusted? Or so they believe in their delusional state. We talk about them behind their backs and that’s gotta hurt because they know if they mention it their ill, seriously ill lmao.
    I must be honest I’m so glad to not have to be putting up with these frauds and slanderers visiting me on a regular basis. I guess it’s one way for them to make friends, because I don’t think anyone would be their friends willingly. It might explain the high rate of alcoholism among them them also. So they have the courts order them some ‘companions’ lol
    Best cure for mental health issues, stay away from mental health services.

    I note that in Australia today the Government is going to “restrict the use of chemical restraints” in aged care facilities. A recognition that they are damaging and a violation of human and civil rights maybe? Shhhh not too loud people will be looking at the interim report and using the information and claiming it might be best they are restricted in other areas too. And we don’t want the idea catching on.

  6. Hugs Francesca!

    The only cure I could find for my “bipolar” was fleeing the MI System.

    The drugs were actually causing my mood swings and hallucinations. Though I think “good insight” also plays a role.

    William Glasser described “psychotic” hallucinations as “creative symptoms.” Of course mind altering drugs just add a new element to the mix.

    We need to offer real, human help to those like you in need, Francesca.

  7. Great blog post, Francesca. It is my view that we need a more effective underground network of support, a railroad so-to-speak, to help people escape from forced treatment of all sorts, and even, very much so, the threat of such forced treatment that comes with Assertive Community Treatment teams, another one of those lying acronyms like Assisted Outpatient Treatment for forced drugging. I’ve had first hand experience with ACT teams, and what people need, by and large, is protection from them and the people behind them. Transport a person threatened with forced treatment to another part of the country where that threat doesn’t exist, and where they have the resources and the means to subsist and thrive, and “mental illness”, *cough, cough*, the “mental health treatment” system, death and destruction by another name, have lost that round while independent living and human rights have won the day.

    • Frank Blankenstein, I believe Francesca is in BC Canada? I think it might be worse there than in some other provinces? The biggest problem in Canada is that our information is ALL visible. To everyone within the medical community. If you wind up in ER, they have every single visit to every doc on file, and there is a huge problem with less healthcare, shoddy, snotty, disparaging, for those with even a HINT of one visit to a shrink. It might be possible to move provinces but if you’re not willing to share med info within the new province, it raises suspicion and the cycle starts over. If they want access, they can get it. It’s depressing to live with such absolute powers. “Well doc, I been depressed over the absolute powers you hold” The next DSM will have something called “medical depression”. The only thing I can think of is to move to a small town in another province, but then it’s not ideal.

      • Yes Sam you’re right about electronic records in Canada. The system is ‘Netcare’ in the provinces but I saw on the news it’s now switching to an upgraded system called ‘Connect Care’. The Chief Medical Information Officer stated this “We are making sure the patient’s story remains intact and unbroken so everywhere they go all health care providers are on their story, which is 19,000 front line medical staff and includes, doctors, mental health and addictions, labs, pharmacists etc”.
        I believe the ultimate goal is to have patient records be not just province wide but country wide.

        • Scary!
          In America at least our records don’t follow us. Yet.

          I’m forced to use Medicaid. But i tell people I’m on disability for IBD. I actually have the diagnosis and see a GI and cancer specialist for it. (Can’t absorb iron and other nutrients.)

          Ironically my condition was caused by long term psych drug use–though no one will admit it. My heart is better, no longer pre diabetic, and have lost 50+ pounds and still losing. In my forties. For the first time.

          • Still a few Peter Breggins out there.

            Long before I heard about Robert Whitaker, I learned the truth about psychiatry from rogue psychiatrists–like William Glasser and Terry Lynch.

            Far from upsetting me, the idea that the pills were not fixing my brain but harming it, was a great relief. I had often felt frustrated and depressed that my effective, neuro-protective pills weren’t helping me lead a happy, productive life like the MH people kept promising. No one else at the MH center seemed that “functional” either.

      • It’s Frank Blankenship, not -stein, and things could be pretty bad in Canada, but they’re pretty bad throughout the USA as well. Ditto, the world. The old idea about getting people out of the country and into Canada if you’re from the states, or into the USA if you’re from Canada, when you free them from an institution. still apply, as far as I know. We’re talking about outpatient situations here though where the situation is, frankly, not quite so severe. In the USA, lacking a federal mandate, a person is generally out of hot water once transported to another state. If simply moving a person from one province to another doesn’t work, moving them to another country should. I’m not talking strictly legal means. Underground is underground, and there the public record goes blank.

        • ooops, sorry about changing your name. I do think moving beats feeling oppressed on a daily basis. I think people having to move or hide really exposes the manner in which these tyrants work. I like rebellion, because they understand nothing else. There is no ‘rationality’, no possible way to reason with them, which includes the medical people. My attitude is, no system can own me.

  8. I saw a guy do a ‘bunk’ while i was in hospital here, and he headed off to another State with assistance from some ‘friendlies’.

    Know your enemy, know yourself.

    So I watched the staff to see what they did about this prisoner absconding. It seems that there is a National database that is activated when this occurs and they detain and transport people back, no matter where they are in the country. And of course you are not going to be using you passport to get out, this place is an Alcatraz in that sense. But a bit like Cool Hand Luke I hope the guy is living it up in a casino somewhere rather than being force drugged in a filthy cell they call a hospital.

  9. Thanks for sharing your story Francesca. It is very painful to realize how many people become trapped in the clutches of psychiatry and endlessly suffer from inhumane labels and treatment. In every personal story it’s evident anyone who sees a psychiatrist, especially if the psych drugs don’t magically transform their life, current hardships or situation, will likely get the same descriptions, aka accusations, written about them, such as “lacks insight”, “treatment resistant”, etc. In the world of psychiatry it is as though people are all clones or duplicates and the same descriptions apply to everyone! It is so stupid it would be hilarious if it wasn’t so blatantly damaging to so many innocent people. It is stomach turning to read how you must pacify these people and tell them what they want to hear and unfortunately this is the sickening truth. I am in Canada and had not known how crazy psychiatry was until I saw an arrogant psychiatrist for insomnia while in cancer treatment. She was very young (had just graduated and began practicing) but was already cold, calculated and deceptive. Unfortunately it is just as bad in Canada as it is in the US and many other countries. Thanks for adding your voice on MIA, and thank God for MIA!! We must all keep speaking out and fighting this corruption and destruction of innocent lives. Stay strong, keep speaking out. I am wishing you all the best Francesca.

  10. Whoa…your writing style is so refreshing…. Lacking self pity & extra editorializing.

    I recognized your experiences with ACT, as I was an 11-year vet…..you nailed it beautifully.

    Your clarity and self-awareness is sharp & strong. You have boatloads to offer on this and I’m guessing alot more.

    Keep writing, Ms. Simpson. You’re a welcome & incisive contribution to this publication.

    There is opportunity amidst chaos.