MYTHS Versus REALITIES OF Assisted Outpatient Treatment (AOT) FROM LENS OF mobile emergency psychiatric clinician ON FRONT LINES

Assisted Outpatient Treatment (AOT) is a program under court order that motivates adults with serious mental illnesses who’ve had difficulty in adhering to voluntary treatment to engage in treatment. Civil courts and mental health agencies work together in AOT to reduce the frequency of inpatient hospitalizations and incarcerations.

AOT encourages treatment teams to keep the recipients in treatment. An AOT request can be initiated as part of discharge planning on an inpatient unit, directly from an outpatient setting in the community, and upon release from jail or prison into the community. 

Forty-seven states and Washington D.C. allow AOT. Only three states, Maryland, Connecticut, and Massachusetts, lack AOT laws. Although AOT has become more accepted by mainstream society, controversy still exists because of myths. While I testified in favor of AOT at the state house in Massachusetts three times over the last several years, the strongest opposition came from peer specialists.

AOT MYTHS versus realities

MYTH: AOT is ineffective because there aren’t any consequences for treatment non-adherence.

REALITY: Judges are not allowed to punish AOT recipients for non-adherence, but there can be consequences. The judge periodically meets with the recipient to reinforce the order. The length of the AOT program can be extended. The judge could order an emergency psychiatric evaluation. Rehospitalization on an inpatient unit might occur. 

MYTH: AOT is not person-centered and doesn’t align with the recovery model. 

REALITY: Although self-direction is limited at the beginning of the order, principles of the recovery model and person-centered care are used daily in AOT. Self-direction is preferred and should be maximized. Person-centered care can be emphasized even when recipients are not adhering to treatment. Using such an approach increases the chance of treatment adherence and positive outcomes. AOT does not necessarily lead to an increased sense of coercion. 

MYTH: AOT is too expensive. 

REALITY: Costs of AOT are small in comparison to the cost of inpatient care and incarceration. AOT is an evidence-based tool that typically results in fewer hospitalizations, fewer arrests, a decrease in homelessness, and fewer incarcerations. AOT saves money because hospitalization is far more expensive than outpatient care. 

MYTH: Comprehensive outpatient services that are voluntary would eliminate the need for AOT.

REALITY: Many people with serious mental illness are incapable of engaging in treatment voluntarily because of their illness. Many of them have anosognosia, which is a lack of awareness of one’s own illness. By obligating mental health agencies and courts to engage them, AOT ensures that treatment interventions will be used for people who are most sick. 

AOT is a humane, reasonable, and evidence-based tool for people with psychosis who’ve had difficulty adhering to treatment. Widespread research has shown that AOT improves the overall functioning of its recipients.

Addendum by Kerry Martin, CEO, accelerating social good

For those interested in learning more about AOT and how it is used to help those most at risk for the negative and sometimes deadly consequences of not receiving treatment, additional reading follows:

• A 2 page overview of AOT published by Treatment Advocacy Center (of particular note, for participants in New York’s AOT program, called Kendra’s Law: 77% experienced fewer psychiatric hospitalizations, 74% fewer experienced homelessness, 83% fewer experienced arrest, and 87% fewer experienced incarceration)
• Personally Speaking: Assisted Outpatient Treatment Saved My Life, an article by Eric Smith, MSW, mental health advocate, and public speaker on matters of mental illness
• Powerful OpEd, Gabe Damour's Death Was the Worst Nightmare Come True for Families Like Ours, by Jeanne Gore, Yaicha Provencher, Joe Pickering, Jr published in Sun Herald January 1, 2023 speaking to why there is an urgent need to expand and utilize Maine's AOT program

GUEST Author

Lynn Nanos heads the Blogging Committee for National Shattering Silence Coalition Nonprofit, our pro bono client, and is also a member of their Steering Committee. She is a licensed independent clinical social worker employed as a full-time mobile emergency psychiatric clinician in Massachusetts. She evaluates patients in homes, jails, residential programs, day treatment programs, rest homes, hospital emergency rooms, and inpatient medical units, determining if patients are presenting a danger to themselves or others. She also authorizes and implements involuntary transfers of individuals to hospitals or refers them to residential treatment, outpatient care, or crisis stabilization units.​​​

​​​​​​​​​Lynn is the author of the book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry. She’s petitioned NAMI to include AOT in their advocacy efforts and testified for AOT in the Massachusetts legislature.

With a master of science in social work from Columbia University, Lynn also worked as an inpatient psychiatric social worker. On inpatient, she assessed adults for danger to self or to the community, and self-care ability. She referred them to aftercare treatment or advocated with insurance companies for their continued stay.