Implementation Status of Assisted Outpatient Treatment Programs: A National Survey

Statutes for involuntary community mental health treatment have been broadly adopted in the United States; in fact, 45 states have statutes authorizing assisted outpatient treatment (AOT). AOT refers to court-mandated treatment in community mental health settings for individuals who meet stringent criteria. Advocates for AOT consider it an important mechanism to improve the lives of individuals who lack insight into their need for treatment. Numerous studies have found that persons with mental illness benefit from AOT participation; these studies have defined the major criteria of effectiveness as reduction in rehospitalization and recidivism, reduction in violence and victimization, and improvement in quality of life.

Researchers have found that participants in AOT have lower odds of arrest (1,2); reduced risk of victimization (3,4); lower risk of harm to self or others (5,6); reductions in hospital admissions and recidivism, length of hospitalization (7–10), and emergency visits (7); improved engagement in services (9); and higher quality of life (11). However, nearly all reports were from one state only or from outside the United States; most failed to consider the patient’s perspective (12); and nearly all had methodological flaws, ranging from use of retrospective study designs (1,9,10) to absence of a control group (7), nonrandom assignment to AOT (3,6,9), nonrandom extension of AOT orders (8,11), and exclusion of persons with a history of violence (12). Attempts to produce definitive evidence of the effectiveness of AOT may be “a quixotic quest” (13), given how many questions remain about the use of AOT (4,14). In fact, mandated service programs remain highly controversial because of concerns that they require coercion to achieve improvement in treatment engagement and have the potential to divert resources from programs for clients seeking voluntary mental health services (5,11).

Engagement of the “revolving door” individual, someone who has repeatedly avoided long-term treatment despite recurring crises, is a major objective of the AOT strategy. Thus most AOT programs and, consequently, many of the studies evaluating AOT have focused on patients who were referred as they transitioned into the community from inpatient mental health facilities or, in a few cases, prisons or jails. Yet many families and advocates also see AOT as filling a need for a treatment “gateway” for members of the community who may be severely ill but who are not engaged in treatment and do not meet the criteria for hospitalization. A secondary objective that often drives the passage of AOT legislation is the hope that treatment will forestall violence by individuals with mental illness; yet such violence is rare and notoriously difficult to predict (15). Thus the literature appears to indicate that AOT is best defined as a service, involving the collaboration of courts and treatment providers, to recruit individuals with mental illness who may be at risk of grave disability, of deterioration, of self-harm, or of violence to others and engage them in outpatient treatment (16). The literature further suggests that AOT is considered appropriate both for individuals who are leaving institutions and for those with untreated mental illness who are living in the community.

Despite growing interest in AOT and the existence of AOT statutes in 45 states, little is known about the ways in which individual states have utilized this mechanism and the ways in which utilization varies from state to state. The most extensive evaluation of the use of AOT to date was a qualitative review carried out by researchers at RAND Health in 2001 (16). The researchers reviewed all the available AOT statutes and conducted detailed informant interviews in eight states. Their major finding was that AOT had had limited and inconsistent implementation. Many states used AOT primarily in hospital discharge planning, and informants from the selected eight states reported a lack of adequate treatment resources, lack of “teeth” for enforcement, and inadequate monitoring and data tracking capability. The conclusion of the RAND researchers was that “outpatient commitment is neither as effective a solution to the problem of compliance as its advocates claim nor, in its practical application, as repressive a law as consumer/survivors fear” (16). The report and other recent research suggest that many states have AOT statutes that are unused or used sporadically (16,17). For an accurate assessment of AOT programs that can guide future policy, it is important to examine how these programs are currently implemented, how patients are enrolled in AOT and through what pathways, and the types of common problems that arise in practice.

The purpose of this study was to describe the actual operation of AOT programs in practice nationally in 2014 rather than in terms of models discussed in the literature (18) or of statutory variance. Our approach used a qualitative survey design and an analysis that involved four steps. First, we reviewed and compared the statutory criteria and procedures for AOT in 45 states to inform our development of interview items. Second, we collected interview data to determine the extent to which AOT had been implemented in each state and the availability of data on implementation. Third, we developed a simple set of enrollment pathway descriptors that reflected our findings on how AOT had been implemented in practice. Finally, we compiled strengths and limitations of the programs most often identified by our informants.