What is AOT?
Assisted Outpatient Treatment (AOT) is a court-ordered, involuntary directive that an individual must work with a treatment team for up to one year. It’s a civil order, not part of the criminal court system – it’s different from Mental Health Court. Its main goal is to keep people out of criminal court, where they might end up on charges like trespassing and assault, by keeping their brain in better health and oriented to reality. A simple way to think of AOT is that it’s a deal made between a civil court and an individual with severe brain function illness: you may live in our community if you follow these rules and work with treatment.
Pennsylvania law began to permit counties to set up AOT programs with a change in law in 2018. Counties can’t invoke the AOT law until they set up programs dedicated to making sure that every individual gets legal due process and medical oversight. To date, no county in Pennsylvania has taken the step of using an AOT program, though some are exploring what it would take. (Read: Juliette Rihl at Publicsource.org asks (2019) why no counties have set anything up yet)
What does an AOT program look like?
In New York and other states, treatment teams can put together a plan for an individual that includes talk therapy, medication compliance checks (blood levels), day programs, supervised living situations, and anything else that would materially improve the person’s ability to make it in life.
Who can file an AOT petition?
This varies by state. Pennsylvania’s law states that “any responsible person” can file a petition, with an attached statement by a psychiatrist or licensed psychologist. The petition sets forth “reasonable cause,” an explanation of why this person needs the court to be involved. This petition is then evaluated at a hearing where the individual is present, with a lawyer.
How is AOT different from Involuntary Outpatient Treatment (IOT)?
IOT court orders last for only 90 days before they must be renewed, compared to AOT’s 12-month period. IOT court orders also must meet the old “danger standard,” proving that death or serious harm has occurred or will occur within 30 days past or future. AOT petitions don’t require imminent danger, since “need for treatment” is a broader range. Because AOT gives the court broader powers, it must also be overseen by a dedicated program, while IOT is not overseen by a team. Both types of order will be possible after a county has opted into AOT implementation.
What happens if someone stops cooperating?
Broadly, complying with an AOT program is required to be allowed to live in the community, but it isn’t usually policed strictly – there is no arrest warrant for someone who misses meetings or doses, or who says they won’t comply anymore. But the AOT team has the authority to send someone to the hospital if he or she starts to “decompensate,” that is, to fare badly by being out of reality or losing self-care. State law for involuntary hospitalization still has the “clear and present danger” standard, but an AOT team is not required to wait for things to get as bad as that. Once someone is under an AOT order, it is much easier to admit them to prevent further chaos.
New York’s Pioneering AOT Program
In the United States, the first AOT program was set up in New York State in 1999, when Kendra’s Law was signed. Kendra Webdale died in January 1999 when a man with severe untreated paranoid schizophrenia pushed her onto the tracks of a moving subway train. Working with her family, the NY Attorney General’s office sought to craft an ongoing, innovative solution to the problem. Brian Stettin, an attorney on the AG’s staff, took the lead in writing a proposal that moved quickly so that it became state law by the end of 1999.
Since the late 1960s, state law had made it very difficult to “commit” someone to a psychiatric hospital. New York was the first state to create an alternative to the standard of “clear and present danger.” Kendra’s law permitted intervention when someone was “unlikely to survive safely in the community without supervision” and had refused treatment multiple times. If the individual stopped cooperating with treatment, the AOT team could have him or her re-hospitalized without needing to meet the danger standard.
Evidence from New York’s Experience
Since 1999, over 35,000 AOT petitions were filed, and most of them were granted. About 75% of these petitions are for treating paranoid schizophrenia, another 15% for bipolar disorder, and the remaining 10% for other problems. One-quarter of the AOT individuals had been homeless at some point, either when the petition was filed or previously, and about the same number had also been in jail. There were two male AOT clients for every one female. About 60% of NY’s AOT cases lasted six months to a year, with another 30% that needed more time.
When social workers followed up with AOT recipients after they left the program, far fewer of them were homeless, inpatient in a hospital, or in jail. Rates of these poor outcomes were reduced by 65-75%. Drug and alcohol abuse went down by about 30%, but incidents like physical or verbal assault, public disturbance and attempted suicide decreased by 50%.