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 2×2 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’s[1. All patients described here are composites of people I have seen across time.] 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 YOOOOORK… CONCRETE 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.
Maria Yang, MD 