Courts in nearly every state have the authority to mandate outpatient treatment for certain individuals with mental illness who have been unwilling or unable to access needed treatment voluntarily. It’s called “Assisted Outpatient Treatment” (or “AOT”).
With Kendra’s Law in 1999, New York State was at the forefront of the national movement to adopt AOT. The policy was controversial then and remains controversial today. Both supporters and opponents are now citing a new, 392-page independent evaluation of AOT in New York. The report compared AOT with a comparable, but voluntary, intensive outpatient program called “Assertive Community Treatment” (or “ACT”).
The Controversy Continues
Supporters of AOT focus on the study’s quantitative results. The executive summary lists four outcomes where AOT did significantly better than ACT, two outcomes where ACT did significantly better, and four with no statistically significant differences (exhibit 1, page 3).
Notably absent from the executive summary is one of the primary justifications for AOT, medication adherence, where voluntary ACT did significantly better (exhibit 4.26, page 177). There were no significant differences between AOT and ACT on three other key outcomes also not listed in the summary: risk of harm to self, support needed for independent living, and employment.
AOT skeptics, including an author of the study, argue that the quantitative findings are being misinterpreted. For example, even though AOT improved housing by a greater statistical margin than ACT, ACT improved housing outcomes for many more people than AOT.
For those keeping score, dropping the disputed housing outcome and adding medication adherence to the list of key outcomes would result in a three-to-three tie between AOT and voluntary ACT, plus many more outcomes with no statistically significant differences.
But the main criticism of AOT, based on qualitative data, is that many participants feel confused, coerced, and powerless. These real costs should break the tie in favor of voluntary ACT, the argument goes. The law agrees.
Least Restrictive Alternative
Under New York statute, a court is authorized to order AOT only if “there is no appropriate and feasible less restrictive alternative.” It doesn’t take qualitative data to recognize that a voluntary program is less restrictive than a mandatory one.
To be sure, the new report did not attempt to determine whether the “less restrictive alternative” requirement was met in any particular case, let alone in the thousands of cases included in the study. But the report includes enough data to suggest that New York City, which accounts for a very large share of AOT orders statewide, is not meeting this legal requirement.
New York City Exceptionalism
First, there is woefully inadequate access in NYC to voluntary ACT, which the quantitative data discussed above shows could be a viable less restrictive option than AOT. Specifically, the wait time in NYC for ACT without an AOT order is over two years (table 3a, page 279). Voluntary ACT programs are more readily available in every other region of the state.
Second, NYC is the only region in the state in which courts never consider another less restrictive outpatient option before ordering AOT, the “Enhanced Voluntary Agreement” (or “EVA”) (table 13a, page 302). Voluntary pre-AOT diversion interventions have been shown to avoid the need for involuntary treatment for many individuals with serious mental illness.
A final piece of data in the report supports the conclusion that NYC is overusing AOT: the city has far fewer significant negative events among AOT participants than any other region (exhibit 4.23, page 172). Sure, it’s possible that the AOT program in the city is better than AOT elsewhere in the state, but a more plausible explanation is that a higher percentage of AOT participants in NYC would have avoided bad outcomes without the force of a court order.
Conclusion
No single study will resolve the long-running and heated controversy over AOT. But the recent report strongly suggests that NYC is not providing, or even considering, some voluntary alternatives to AOT that are used successfully elsewhere in the state. Forced psychiatric treatment is supposed to be a last resort. At least in NYC, it does not appear to be.