Assisted outpatient treatment (AOT), also known as outpatient commitment (OPC), is a civil legal procedure whereby a judge can order an individual with a serious mental illness to follow a court-ordered treatment plan in the community. AOT is intended for adults diagnosed with a serious mental illness who are unlikely to live safely in the community without supervision and treatment, and who also are unlikely to voluntarily participate in treatment. The goal of AOT is to improve access and adherence to intensive behavioral health services in order to avert relapse, repeated hospitalizations, arrest, incarceration, suicide, property destruction, and violent behavior.
Forty-four states have statutes permitting some form of OPC or AOT (Robbins et al. 2010). One example is New York State’s “Kendra’s Law.” The law, passed in 1999, which was proposed by the New York State Attorney General, was named for a young woman who was killed after being pushed in front of a New York City subway by a man with a history of serious mental illness and hospitalizations. The intent of the law was not only to authorize court-ordered community treatment but also to require mental health authorities to provide resources and oversight necessary so that high-risk individuals with serious mental illness may experience fewer incidents and can live in a less restrictive alternative to incarceration or involuntary hospitalization.
AOT is designed to ensure that service providers and county administrators deliver appropriate services to high-risk, high-needs individuals. Case managers, Assertive Community Treatment (ACT) team members, other clinical service providers, county personnel and attorneys, recipient advocates, and family members are among those who participate in AOT–related activities.
Under New York State’s Kendra’s Law, local AOT coordinators were created to monitor and oversee the implementation of AOT for each county and New York City. These local coordinators accept and investigate reports of individuals who may require AOT and arrange for the preparation of treatment plans and filing of petitions for AOT in local courts. Existing local programs are responsible for oversight and monitoring of clients by providing case management services. The case managers and ACT team members are in charge of directly monitoring an AOT recipient’s level of compliance and delivery of services by other providers pursuant to the court order. Case managers and ACT team members report to local AOT coordinators on an individual’s treatment status.
Under New York’s Kendra’s Law, a person may be ordered to receive AOT if: the person is eighteen or older; suffers from a mental illness; has a history of lack of compliance with treatment that has at least twice within the last 36 months been a significant factor in necessitating hospitalization, or incarceration; or within the last 48 months, resulted in one or more acts or threats of serious violent behavior toward self or others and is unlikely to survive safely in the community without supervision. It must also be established that AOT is the least restrictive alternative. For some individuals, a voluntary service agreement may be signed in lieu of a formal court order. Individuals must agree to receive enhanced voluntary services, which usually include case management or ACT.
Kendra’s Law established mechanisms so that local mental health systems give individuals entering AOT priority access to case management and other mental health services that are essential to treating an individual’s mental illness, avoiding relapse that would lead to arrest, incarceration, violence, self-harm, or rehospitalization, and helping the individual live in the community. Mandatory treatment plans are developed and implemented to ensure that comprehensive, community-based services are provided to AOT recipients by mental health officials. There is a wide range of services that can be included in the treatment plan, such as case management, medication management, individual or group therapy, day programs, substance abuse testing and services, housing or housing support services, and urine or blood toxicology (to ensure adherence to medication).
In many States, no court order goes into effect unless a treatment plan has been submitted to the court. The length of the court order can vary by individual. Court orders may not last longer than 6 months unless they are renewed by the court. When the court order expires, and it is not renewed, individuals continue receiving voluntary services. Noncompliance can lead to a temporary hold to evaluate for involuntary hospitalization.
18 to 50
Gilbert and colleagues (2010) found that the odds of arrest in any given month for participants who were currently receiving Assisted Outpatient Treatment (AOT) were significantly lower than the odds for participants in the pre–AOT and prevoluntary agreement group (the reference group). The odds of arrest were nearly two thirds lower for participants currently receiving AOT, compared with the odds of arrest for the reference group.
However, there were no statistically significant differences in the odds of arrest between those with a current voluntary agreement and those in the reference group. The adjusted predicted probabilities of arrest in any given month were 3.7 percent for the reference group, 2.8 percent for individuals currently under a voluntary agreement and 1.9 percent for individuals currently on AOT.
Within-group analyses conducted by Link and colleagues (2011) showed that the risk of arrest was significantly higher for individuals during the period before Assisted Outpatient Treatment (AOT) than during the period of AOT. Though the risk of arrest went up slightly in the period after AOT was discontinued, this difference was not significant. For an individual who had ever received AOT, the risk of any arrest was 2.66 times greater before AOT as it was while receiving AOT.
The between-group results showed that the risk of arrest among individuals in the comparison group who were never assigned to AOT was significantly higher than the risk of arrest for the AOT group while they were assigned to AOT. Compared with individuals during and shortly after the period of assignment to AOT, the comparison group who never received AOT had nearly double the odds of arrest.
Arrests for Violent Offenses
Within-group analyses found that individuals receiving AOT were at significantly lower risk of arrest for a violent offense than they were before AOT. The risk of arrest for a violent offense was 8.61 times greater before AOT as it was while receiving AOT. However, because arrests for violent offenses were relatively rare, between-group analyses found there were no significant differences between the AOT and comparison groups on the odds of arrest for violent offenses.
An initial analysis performed by Swanson and colleagues (2000) found there was no significant difference in the rate of violence between the group randomly assigned to involuntary outpatient commitment (OPC) and the control group (32.3 percent in the OPC group versus 36.8 percent in the control group).
However, multivariate analysis showed that controlling for baseline history of violence and substance misuse, extended OPC was associated with significantly lower odds of any violent behavior during the year of the study. Treatment group members who received more than 180 days of OPC were only about one third as likely to commit a violent act during the year, compared with their control group counterparts. However, treatment group members receiving fewer than 180 days of OPC did not differ from the control group with respect to risk of violence.
Extended Outpatient Commitment
This initial analysis did not include the seriously violent group, nor was the length of exposure considered. When study participants with a history of serious violence were included in the analysis and the OPC intervention was defined as having received at least 6 months of court-ordered treatment, the treatment group had a significantly lower rate of violence during the year, compared with the control group (26.7 percent, versus 41.6 percent). This result should be viewed with caution, because the analysis included participants with a history of serious violent behavior who were not randomized to treatment.
Extended Outpatient Commitment Combined With Regular Community-Based Services
Additional analysis looked at whether OPC interacts with the provision of outpatient services to reduce the risk of violent behavior. An initial analysis found that OPC alone did not significantly reduce the risk of violent behavior. Similarly, receiving frequent outpatient services alone was not associated with less violence. However, a combination of both variables (at least 6 months of OPC with an average of three or more outpatient visits per month in the community) did significantly reduce the risk of violence. The predicted probability of any violent behavior was cut in half, from 48 percent to 24 percent, attributable to extended OPC and regular outpatient services. Again, this result should be viewed with caution, because the amount of time on OPC was neither random nor controlled for experimentally.