ASSISTED OUTPATIENT TREATMENT : "A STEP IN THE RIGHT DIRECTION"
"But the voices…the voices told me to stab Mom in the heart," Jenny impassively recounted to the judge. Sitting in chairs positioned directly behind their daughter, her worried parents hoped the judge would understand that Jenny was not a bad person, but that she needed help they could not provide.
More than 10 years before, Jenny had been diagnosed with paranoid schizophrenia. Since then she had been taking medication prescribed by a psychiatrist and seeing a therapist on a fairly regular basis. But in the year before this civil commitment proceeding, Jenny took her medication sporadically and on 3 occasions was admitted to her local hospital's psychiatric ward. Each time she seemed to get better and was released after only a few days.
"I find that the respondent is a mentally ill person subject to hospitalization by court order," the judge delicately decreed, as Jenny's parents silently nodded their agreement. Jenny just stared straight ahead, lost in a world the others could not understand. "I further find that the least restrictive alternative available that is consistent with treatment goals is inpatient hospitalization at the state mental hospital," the judge continued, "and upon discharge from the state hospital, respondent shall be committed to the local mental health board to receive assisted outpatient treatment."
Assisted Outpatient Treatment (AOT) is a form of court mandated outpatient treatment that allows a mentally ill person to be treated in a much less restrictive environment than a state hospital while still allowing judicial monitoring of the administration of the person's treatment plan.
A generation ago, civil commitments to state mental hospitals were best measured in months or years. Assisted outpatient treatment has helped change that expectation. Assisted outpatient treatment (AOT) is a form of court- mandated outpatient treatment that permits a mentally ill person to be treated in a much less restrictive environment than a state hospital while still allowing judicial monitoring of the administration of the person's treatment plan. AOT is an effective alternative to the out-dated "throw away the key" custom of mental health treatment.
This progressive method of treatment mandates that those with a demonstrated inability to maintain psychiatric treatment in the community receive and participate in sustained and intensive treatment until once again able to manage their own treatment regimen. For someone incapable of making informed medical decisions, a typical 6-month authorized placement in an AOT program could mean a safety net of intensive and caring treatment rather than a spiral into psychosis and the intense restriction of an involuntary hospitalization. And, conversely, the intensive supervised treatment of AOT becomes a bar to re-hospitalization and a bridge to stability for many released from inpatient psychiatric facilities.
Any humane and comprehensive quality mental health treatment system must make provision for both inpatient and outpatient involuntary treatment for those severely and/or persistently mentally ill who can benefit from such approaches. i
National Alliance On Mental Illness
NAMI's Policy On Involuntary Commitment similarly holds that "Court- ordered outpatient treatment should be considered as a less restrictive, more beneficial, and less costly treatment alternative to involuntary inpatient treatment."ii Not surprisingly – since many tens of thousands of people with severe mental illness are jailed each year for lack of treatment –
The use of AOT is promoted by correctional and law enforcement organizations like the National Sheriffs' Association, which formally resolved to support "laws that allow a court to order treatment in the community for individuals who are in need of treatment but refuse it (also known as assisted outpatient treatment)."iii
Indeed, more than fifteen published studies have examined outpatient commitment for statistically significant value in facilitating and improving the care of those most affected by the symptoms of mental illness. All but two of those have determined it an effective treatment mechanism. In most cases, researchers have pronounced it a remarkable one.
The legal foundation on which the assisted outpatient treatment process has been built has been validated by a number of court decisions. As it has long been conclusively settled that courts can be empowered to commit individuals overcome by psychiatric disorders to the more restrictive setting of a hospital, judicial orders requiring compliance with treatment in an outpatient setting are clearly permissible. What legal challenges there have been have instead focused on the progressive eligibility standards incorporated in most of the more recent AOT laws.
These criteria include considerations such as the need for treatment, the chances of deterioration absent it, the inability to function independently, and the capability of making informed medical decisions. Such standards have been upheld by the unanimous high courts of three states: Washington (1989), Wisconsin (2002) and New York (2004).ix No significant challenge to an AOT law or its standard has succeeded despite the laws being in place in 41 states, in some of them for over two decades.
Jenny's case is not unique, but her treatment plan is not "the way it used to be done." Just as the discovery of new medications has made mental health treatment more effective, progressive changes in the way courts and treatment professionals handle civil commitment cases can also make mental health treatment more effective. In Jenny's case AOT has worked. At her last status review hearing, Jenny smiled broadly as her mother told the judge, "Jenny is doing better now than she has in the last 12 years."
Progress involves moving forward. Assisted Outpatient Treatment is a step in the right direction.
i APA Task Force, "A Vision for the Mental Health System" (April 2003).
The information on Mental Illness Policy Org. is not legal advice or medical advice. Do not rely on it. Discuss with your lawyer or medical doctor. Mental Illness Policy Org was founded in February 2011 and recently received 501(c)(3) status. In order to maintain independence MIPO does not accept any donations from companies in the health care industry or government. That makes us dependent on the generosity of people who care about these issues. If you can support our work, please send a donation to Mental Illness Policy Org., 50 East 129 St., Suite PH7, New York, NY 10035. Thank you. For more information, http://mentalillnesspolicy.org.