An Advocate’s Observations on Research Concerning Assisted Outpatient Treatment

Abstract

“Assisted outpatient treatment” (AOT) is a practice designed to improve treatment outcomes for people with severe mental illness whose difficulties adhering to voluntary outpatient care have left them trapped in the revolving door of the mental health and criminal justice systems. Under AOT, an individual found to meet strict eligibility criteria is placed under court order to comply with an approved treatment plan as a condition of remaining in the community and receives intensive case management and monitoring. A patient’s substantial violation of the court order typically leads to short-term evaluative detention to determine whether hospital commitment has become necessary. In my work for the Treatment Advocacy Center promoting AOT across the United States, I am often puzzled by the wide gulf between the perceptions of AOT among intelligent and dedicated mental health professionals and the findings of researchers on the effectiveness of AOT in improving treatment outcomes for the most challenging subset of psychiatric patients. The research is good enough to lead one to expect a near-universal embrace of AOTwithin the mental health field, and yet this is hardly the case. While 45 states and the District of Columbia have laws authorizing local mental health systems to practice AOT, implementation of these laws remains spotty in all but a few. Many professionals I encounter seem to have absorbed anti-AOT messages emanating from various mental-health consumer organizations who reflexively oppose any infringement on patient autonomy. Among these messages are patently false claims that the research on AOT is “mixed or inconclusive,” or that the research only suggests AOT might be worthwhile in an exceedingly well-funded system of community-based care. In this article, I hope to set straight the record on the AOT research by summarizing the mountain of positive data, placing the purportedly inconclusive or negative findings in a more intellectually honest context, and putting to rest the pervasive myth that impressive results achieved in New York are rooted in anomalies of that state.