I’ve had odd and contradictory experiences with AOT.
Lots of patients being brought to the ED by AOT for supposedly not taking meds. Patients clearly not decompensated. Calmly sitting and saying that they did. Shrug shoulders, discharged.
On the flip side, had a patient that was clearly decompensating, and their mom told me they weren’t taking meds. When I reached out, AOT said the patient said they were taking their meds so that there was nothing they can do. I explained: “the mom said she’s not taking her meds and with medical certainty I can tell you she is not taking her medications”. They said “well she said she’s taking them, so we can’t do anything”. Shrug shoulders, patient further decompensated and gets involuntary admitted a month later.
"Enforcement" is one of the most variable aspects of the implementation of AOT and we've certainly heard a lot of similar stuff -- inconsistency (and inconsistency driven by a diverse array of factors).
Really interesting. I'm struck by how high the demands are for things to be "evidence-based" when it comes to suggesting less coercive treatment of psychiatric patients. This is a stark example of how low that threshold for "evidence-based" is when it comes to taking away rights and implementing coercive methods. 3 RCTs! I try not to be too flippant about this as these are serious questions. But this is frustrating!
“AOT creates mandated accountability for providers to deliver services.” - this is hugely relevant in areas with chronic underfunding and job vacancies in CMH. The gap in service provision between those with SMI on a TO and those who aren’t is stark, and it can feel like watching a car crash in slow motion waiting for a client to become ‘psychotic enough’ to meet criteria for a TO and access any treatment at all. Looking forward to watching the webinar!
In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment.
Thanks -- I covered this in my webinar, but I'm sure you understand that these were not randomized conditions and should not be understood as such. In the primary analyses -- comparing the two groups randomized (as randomized) there were no significant differences. Sorting through the non-pre-planned analyses that exist (such as here), quasi-experimental and pre-post literature is something I'm planning to do as part of an upcoming webinar and then will create a follow-up report that covers these other findings and study types.
"It's true that you're under arrest, but that shouldn't stop you from carrying out your job. And there shouldn't be anything to stop you carrying on with your usual life." "In that case it's not too bad, being under arrest," said K., and went up close to the supervisor. "I never meant it should be anything else," he replied. "It hardly seems to have been necessary notify me of the arrest in that case," said K.
Here in Sacramento California there is no mandated treatment. No forced medication even through AOT and Care Court. There is a hearing before a judge if you make it that far. Most people who are referred end up in voluntary services or decline services and don't get taken before a judge. While there's supposedly the possibility of being ordered into a 3-day hold in practice this is not being done. Main effect of aot and Care Court here seems to be to bring people to the attention of the Behavioral Health Department who had not come to their attention in the past for some reason. Many decline services and are not sent forward to court. To my knowledge there has been no study of long-term outcomes here.
The case of California is really interesting and a lot we can learn from it. This paper by Sarah Starks at al is a really interesting look at CA's (unique) approach to pre-AOT diversion: https://pubmed.ncbi.nlm.nih.gov/36081900/
Unfortunately, even with maximum efforts as is being done in LA and, arguably here (as a boots on the ground person I don't think the quality of the effort here may match that of LA) less than 40% accept services. This leaves 60% untreated, living in squalor, often physically ill and even dying. I think this serves as evidence that pursuing ONLY a voluntary pathway is not a good one and that there is a place for mandated treatment. This is nearly impossible to get here in our county even when there is enormous evidence that the person is gravely disabled and that conservatorship would have a significantly positive outcome. I know of several cases where someone with a history of conservatorship was released after relatively short periods where they had gotten better if not completely well but were very ill and starving and living with other life threatening conditions within a short period of time. I know of a handful of cases where longer term conservatorships have resulted in stability and step downs to high levels of care (for example to Augmented Board and Cares that are not locked facilities but do have delayed egress) but not to full return to the community where, in my opinion, the person would probably have died or ended up in State prison if released from conservatorship. I fear that this conversation that promotes only voluntary care is a disservice to a tiny minority of people whose illness is so profound and their anosognosia so severe that they will never be able to volunteer, often due to paranoia. I do not believe that these studies always adequately evaluate the outcomes in this group because they are hard to find and can be hard to track for the purposes of these kinds of studies. And there seems to be this attitude that 40% acceptance is good enough and we should abandon the other 60% to their fate. When I hear from a mother of a young man who had been conserved and then released that the hospital ER was able to bring her to her son's bedside so she could be there when he died from a massive infection three days after walking away from her home while she was out grocery shopping, I have trouble seeing how insisting on voluntary engagement is humane and the act of decent human beings toward others who are suffering. As for housing, I know of one relatively young person in their 30s who is refusing all housing due to paranoia and hallucinations. They will NOT accept housing even when offered because, despite lengthy and intense efforts spanning years, they are unable to trust the outreach workers or when they do accept housing they walk away in less than 48 hours due to things like olfactory hallucinations that amp up after a few hours. They honestly believe that their new home smells like shit and won't stay. What then is the answer for them?
I agree wholeheartedly with your assessment of the brokenness of current systems of care. I do not, however, see coercion as anything remotely like a silver bullet. Tremendous harm can be enacted through involuntary commitment — inpatient and outpatient — and people on AOT orders (and for that matter, those in US state hospitals, IMDs, prisons and jails) also very much experience horrific conditions—many remain unhoused, no change in levels of poverty, a degree of social exclusion and de facto segregation that should indeed “shock the conscience”., to say nothing of the truly horrific physical and neurological side effects stemming from high fuse antipsychotics and antipsychotic polypharmacy. AOT simply does not solve these problems and for some functions as its own kind of slow (or not so slow) death sentence. And I’m sure you’re aware of how “anosognosia” gets weaponized in ways that contribute not just to deep invalidation and disempowerment but very real structural violence. The costs and risks here could not be farther from neutral or benign. Certainly we need to hold policy makers to account and demand change — looking to systems such as Trieste as exemplars of what is possible if we truly invest — not in expanded coercion but systems of care that fundamentally address social inclusion and integration, the centrality of human relationships, poverty and housing and that resist the temptation (fantasy?) of top down control. I care very deeply about the fate of people with long term severe psychiatric disabilities in this country — but truly don’t see expanded coercion as the path to addressing the suffering and poverty in question. Do we need to be doing more? Taking action? 100%.
I hear the passion here but I have a question about your relevant question from the article: does the court order produce better outcomes than the same services delivered voluntarily?
Shouldn't the relevant question be does court-ordered services produce better outcomes than no services at all?
I think voluntary services produces a host of confounding factors you already listed such as greater familial support, more resources, and more internal motivation. Furthermore, I think provider quality is something that is controversial to measure. However, many CMH sites are so overrun that most of these services for the most acute of clients are just 15 min med checks with little rapport building.
Got it. Based on what I’ve seen in my research, no. Depending on the jurisdiction and most especially when service access is directly tied to AOT, some people quite desperately want to be on AOT because it’s the only way they can access supported housing or ACT. Many others are actively engaged in services but deemed medication “non-adherent”. Another variation is very much wanting non-coercive (respectful, human centered support) but not being able to access it. No services at all would be a totally false comparison at least for the jurisdictions I’m familiar with.
Hm that's an interesting perspective. Thank you for taking the time to respond. The point about folks wanting AOT because it is the only accessible route for mental health services is damning to say the least.
I know yall know this, and its the thesis of the article and research. No surprise here, we need to support people to have homes, protection from unjust law enforcment action. protection from racism, abelism, and PEOPLE NEED supported housing, with supports. HOUSING is A HUMAN RIGHT. Once again, the Social Support Network has been slashed and burned for TOO long in the United States and outcomes for people and an inablity to get well rounded services costs our nation so much uneeded costs that is- sorry to use the word, but its pathetic, that people do not have the ability to help their neighbors in REAL ways. Individualistic BOOT STRAP idealogy is destined to FAIL. We grow stonger together, Not looking out only for the best interest of an individual. Your a saint, keep using your brilliance to edge us towards JUSTICE for ALL.
I'm a mental health examiner who works for the courts in some civil commitment cases in Oregon. I feel like I'm missing something in this article. I've never seen a patient committed to involuntary hospitalization or involuntary outpatient treatment who would voluntarily participate. That unwillingness to participate in care which is leading to their harm or someone else's harm is an essential part of the commitment process in Oregon. So for an RCT to say that AOT doesn't work better than an equal level of voluntary treatment makes sense. But the better comparison is an AOT vs. no treatment, because the patients I'm seeing committed are not patients willing to engage in any level of treatment.
Extreme cases may require temporary, narrowly defined coercion to preserve life.
AOT or similar interventions should be strictly limited, with clear thresholds, time limits, oversight, and accountability.
Expansion beyond those high-risk, narrowly defined cases is unjustified, especially given the absence of evidence for benefit and the real risks of harm and racial disproportionality.
Here in our county in California, only 179 people out of 1.6 million were conserved the last time I checked.. I don't think anyone can argue that coercive treatment is being handed out willy nilly here. And the outcomes, among the people I know of who are the most ill, match. They are dying, sometimes quickly, sometimes slowly. I am not convinced that these studies are encompassing these outcomes adequately.
I don't buy the control group setup here. More important is why these people specifically were put on court-ordered AOT. If it was because they were given the option of either AOT or some other consequence like prison, then the question is, is doing AOT outside of prison better or worse (and in what ways) than doing it in prison?
I don't understand the part about "coercion." This is literally coercion. If you don't perceive it as coercion, that's a bad thing, because it means you're delusional, no?
I get your point, but perceived coercion isn't self-evident. For instance, do you perceive the criminalization of marijuana as coercive, in the sense that the state is somehow overstepping and restricting your fundamental rights ? What about seatbelt laws ? Also, if the relationship between "literal coercion" and perceived coercion was straightforward, would we expect to find a difference in perceptions on the basis of race ?
Yes, I perceive all laws as slightly coercive, some with an overall positive impact, and others with a negative one. The two you mentioned are actually good examples of laws that make me feel negatively coerced, since I don't need the government to tell me to wear a seat belt any more than I need the government to tell me to brush my teeth.
As others below have pointed out, AOT is often not actually mandatory. In our community, AOT patients sometimes do not even answer the door when the staff come to pick them up for med appointments. People are not returned to the hosptial if they are non compliant In the Steadmen et al study cited in the article, the abstract states, "All results must be qualified by the fact that no pick-up order procedures {police taking to ER or hospital] for noncompliant subjects in the court-ordered group were implemented during the study, which com-promised the differences between the conditions for the two groups, and that persons with a history of violence were excluded from the program" If AOT (as actually implemented) really is not mandated, then it is not surprising we don't see the expected improvements.
Or, alternative take, we are truly and deeply failing folks with long term 'SMI' in this country and yet more police involvement (qua enforcement) and engagement based on threats of said police involvement and/or involuntary inpatient, is not the way to go but rather to face up to the deep structural reforms we desperately need, be clear eyed about it all, and change what needs to be changed.
In my experience, there will always be a tiny fraction of people with the most severe SMI who are UNABLE to agree to services including housing. Their paranoia and hallucinations are so severe that they are unable to trust outreach workers and cannot live in housing safely due to threats to other tenants and workers, assuming their delusions and hallucinations do not drive them out of that housing quickly. What is the answer for these people? How are they represented in this study?
I’ve had odd and contradictory experiences with AOT.
Lots of patients being brought to the ED by AOT for supposedly not taking meds. Patients clearly not decompensated. Calmly sitting and saying that they did. Shrug shoulders, discharged.
On the flip side, had a patient that was clearly decompensating, and their mom told me they weren’t taking meds. When I reached out, AOT said the patient said they were taking their meds so that there was nothing they can do. I explained: “the mom said she’s not taking her meds and with medical certainty I can tell you she is not taking her medications”. They said “well she said she’s taking them, so we can’t do anything”. Shrug shoulders, patient further decompensated and gets involuntary admitted a month later.
"Enforcement" is one of the most variable aspects of the implementation of AOT and we've certainly heard a lot of similar stuff -- inconsistency (and inconsistency driven by a diverse array of factors).
Huh, interesting.
zero insight presentations are such a mood
Really interesting. I'm struck by how high the demands are for things to be "evidence-based" when it comes to suggesting less coercive treatment of psychiatric patients. This is a stark example of how low that threshold for "evidence-based" is when it comes to taking away rights and implementing coercive methods. 3 RCTs! I try not to be too flippant about this as these are serious questions. But this is frustrating!
Many layers of irony.
“AOT creates mandated accountability for providers to deliver services.” - this is hugely relevant in areas with chronic underfunding and job vacancies in CMH. The gap in service provision between those with SMI on a TO and those who aren’t is stark, and it can feel like watching a car crash in slow motion waiting for a client to become ‘psychotic enough’ to meet criteria for a TO and access any treatment at all. Looking forward to watching the webinar!
Yes, definitely. It's just such an inditement of the status quo....
From Swartz 1999:
In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment.
Thanks -- I covered this in my webinar, but I'm sure you understand that these were not randomized conditions and should not be understood as such. In the primary analyses -- comparing the two groups randomized (as randomized) there were no significant differences. Sorting through the non-pre-planned analyses that exist (such as here), quasi-experimental and pre-post literature is something I'm planning to do as part of an upcoming webinar and then will create a follow-up report that covers these other findings and study types.
Oh, I fully agree with your analysis. Glad you are going into the posthoc results.
"It's true that you're under arrest, but that shouldn't stop you from carrying out your job. And there shouldn't be anything to stop you carrying on with your usual life." "In that case it's not too bad, being under arrest," said K., and went up close to the supervisor. "I never meant it should be anything else," he replied. "It hardly seems to have been necessary notify me of the arrest in that case," said K.
Here in Sacramento California there is no mandated treatment. No forced medication even through AOT and Care Court. There is a hearing before a judge if you make it that far. Most people who are referred end up in voluntary services or decline services and don't get taken before a judge. While there's supposedly the possibility of being ordered into a 3-day hold in practice this is not being done. Main effect of aot and Care Court here seems to be to bring people to the attention of the Behavioral Health Department who had not come to their attention in the past for some reason. Many decline services and are not sent forward to court. To my knowledge there has been no study of long-term outcomes here.
The case of California is really interesting and a lot we can learn from it. This paper by Sarah Starks at al is a really interesting look at CA's (unique) approach to pre-AOT diversion: https://pubmed.ncbi.nlm.nih.gov/36081900/
Unfortunately, even with maximum efforts as is being done in LA and, arguably here (as a boots on the ground person I don't think the quality of the effort here may match that of LA) less than 40% accept services. This leaves 60% untreated, living in squalor, often physically ill and even dying. I think this serves as evidence that pursuing ONLY a voluntary pathway is not a good one and that there is a place for mandated treatment. This is nearly impossible to get here in our county even when there is enormous evidence that the person is gravely disabled and that conservatorship would have a significantly positive outcome. I know of several cases where someone with a history of conservatorship was released after relatively short periods where they had gotten better if not completely well but were very ill and starving and living with other life threatening conditions within a short period of time. I know of a handful of cases where longer term conservatorships have resulted in stability and step downs to high levels of care (for example to Augmented Board and Cares that are not locked facilities but do have delayed egress) but not to full return to the community where, in my opinion, the person would probably have died or ended up in State prison if released from conservatorship. I fear that this conversation that promotes only voluntary care is a disservice to a tiny minority of people whose illness is so profound and their anosognosia so severe that they will never be able to volunteer, often due to paranoia. I do not believe that these studies always adequately evaluate the outcomes in this group because they are hard to find and can be hard to track for the purposes of these kinds of studies. And there seems to be this attitude that 40% acceptance is good enough and we should abandon the other 60% to their fate. When I hear from a mother of a young man who had been conserved and then released that the hospital ER was able to bring her to her son's bedside so she could be there when he died from a massive infection three days after walking away from her home while she was out grocery shopping, I have trouble seeing how insisting on voluntary engagement is humane and the act of decent human beings toward others who are suffering. As for housing, I know of one relatively young person in their 30s who is refusing all housing due to paranoia and hallucinations. They will NOT accept housing even when offered because, despite lengthy and intense efforts spanning years, they are unable to trust the outreach workers or when they do accept housing they walk away in less than 48 hours due to things like olfactory hallucinations that amp up after a few hours. They honestly believe that their new home smells like shit and won't stay. What then is the answer for them?
I agree wholeheartedly with your assessment of the brokenness of current systems of care. I do not, however, see coercion as anything remotely like a silver bullet. Tremendous harm can be enacted through involuntary commitment — inpatient and outpatient — and people on AOT orders (and for that matter, those in US state hospitals, IMDs, prisons and jails) also very much experience horrific conditions—many remain unhoused, no change in levels of poverty, a degree of social exclusion and de facto segregation that should indeed “shock the conscience”., to say nothing of the truly horrific physical and neurological side effects stemming from high fuse antipsychotics and antipsychotic polypharmacy. AOT simply does not solve these problems and for some functions as its own kind of slow (or not so slow) death sentence. And I’m sure you’re aware of how “anosognosia” gets weaponized in ways that contribute not just to deep invalidation and disempowerment but very real structural violence. The costs and risks here could not be farther from neutral or benign. Certainly we need to hold policy makers to account and demand change — looking to systems such as Trieste as exemplars of what is possible if we truly invest — not in expanded coercion but systems of care that fundamentally address social inclusion and integration, the centrality of human relationships, poverty and housing and that resist the temptation (fantasy?) of top down control. I care very deeply about the fate of people with long term severe psychiatric disabilities in this country — but truly don’t see expanded coercion as the path to addressing the suffering and poverty in question. Do we need to be doing more? Taking action? 100%.
I hear the passion here but I have a question about your relevant question from the article: does the court order produce better outcomes than the same services delivered voluntarily?
Shouldn't the relevant question be does court-ordered services produce better outcomes than no services at all?
I think voluntary services produces a host of confounding factors you already listed such as greater familial support, more resources, and more internal motivation. Furthermore, I think provider quality is something that is controversial to measure. However, many CMH sites are so overrun that most of these services for the most acute of clients are just 15 min med checks with little rapport building.
Got it. Based on what I’ve seen in my research, no. Depending on the jurisdiction and most especially when service access is directly tied to AOT, some people quite desperately want to be on AOT because it’s the only way they can access supported housing or ACT. Many others are actively engaged in services but deemed medication “non-adherent”. Another variation is very much wanting non-coercive (respectful, human centered support) but not being able to access it. No services at all would be a totally false comparison at least for the jurisdictions I’m familiar with.
Hm that's an interesting perspective. Thank you for taking the time to respond. The point about folks wanting AOT because it is the only accessible route for mental health services is damning to say the least.
Yes, definitely. It’s really just such an inditement of the status quo…
I know yall know this, and its the thesis of the article and research. No surprise here, we need to support people to have homes, protection from unjust law enforcment action. protection from racism, abelism, and PEOPLE NEED supported housing, with supports. HOUSING is A HUMAN RIGHT. Once again, the Social Support Network has been slashed and burned for TOO long in the United States and outcomes for people and an inablity to get well rounded services costs our nation so much uneeded costs that is- sorry to use the word, but its pathetic, that people do not have the ability to help their neighbors in REAL ways. Individualistic BOOT STRAP idealogy is destined to FAIL. We grow stonger together, Not looking out only for the best interest of an individual. Your a saint, keep using your brilliance to edge us towards JUSTICE for ALL.
I'm a mental health examiner who works for the courts in some civil commitment cases in Oregon. I feel like I'm missing something in this article. I've never seen a patient committed to involuntary hospitalization or involuntary outpatient treatment who would voluntarily participate. That unwillingness to participate in care which is leading to their harm or someone else's harm is an essential part of the commitment process in Oregon. So for an RCT to say that AOT doesn't work better than an equal level of voluntary treatment makes sense. But the better comparison is an AOT vs. no treatment, because the patients I'm seeing committed are not patients willing to engage in any level of treatment.
This.
Extreme cases may require temporary, narrowly defined coercion to preserve life.
AOT or similar interventions should be strictly limited, with clear thresholds, time limits, oversight, and accountability.
Expansion beyond those high-risk, narrowly defined cases is unjustified, especially given the absence of evidence for benefit and the real risks of harm and racial disproportionality.
Here in our county in California, only 179 people out of 1.6 million were conserved the last time I checked.. I don't think anyone can argue that coercive treatment is being handed out willy nilly here. And the outcomes, among the people I know of who are the most ill, match. They are dying, sometimes quickly, sometimes slowly. I am not convinced that these studies are encompassing these outcomes adequately.
I hear you. The data suggests that it’s extremely vulnerable to abuse though. We shouldn’t take that lightly. How it’s implemented matters.
I don't buy the control group setup here. More important is why these people specifically were put on court-ordered AOT. If it was because they were given the option of either AOT or some other consequence like prison, then the question is, is doing AOT outside of prison better or worse (and in what ways) than doing it in prison?
I don't understand the part about "coercion." This is literally coercion. If you don't perceive it as coercion, that's a bad thing, because it means you're delusional, no?
I get your point, but perceived coercion isn't self-evident. For instance, do you perceive the criminalization of marijuana as coercive, in the sense that the state is somehow overstepping and restricting your fundamental rights ? What about seatbelt laws ? Also, if the relationship between "literal coercion" and perceived coercion was straightforward, would we expect to find a difference in perceptions on the basis of race ?
Yes, I perceive all laws as slightly coercive, some with an overall positive impact, and others with a negative one. The two you mentioned are actually good examples of laws that make me feel negatively coerced, since I don't need the government to tell me to wear a seat belt any more than I need the government to tell me to brush my teeth.
As others below have pointed out, AOT is often not actually mandatory. In our community, AOT patients sometimes do not even answer the door when the staff come to pick them up for med appointments. People are not returned to the hosptial if they are non compliant In the Steadmen et al study cited in the article, the abstract states, "All results must be qualified by the fact that no pick-up order procedures {police taking to ER or hospital] for noncompliant subjects in the court-ordered group were implemented during the study, which com-promised the differences between the conditions for the two groups, and that persons with a history of violence were excluded from the program" If AOT (as actually implemented) really is not mandated, then it is not surprising we don't see the expected improvements.
Or, alternative take, we are truly and deeply failing folks with long term 'SMI' in this country and yet more police involvement (qua enforcement) and engagement based on threats of said police involvement and/or involuntary inpatient, is not the way to go but rather to face up to the deep structural reforms we desperately need, be clear eyed about it all, and change what needs to be changed.
In my experience, there will always be a tiny fraction of people with the most severe SMI who are UNABLE to agree to services including housing. Their paranoia and hallucinations are so severe that they are unable to trust outreach workers and cannot live in housing safely due to threats to other tenants and workers, assuming their delusions and hallucinations do not drive them out of that housing quickly. What is the answer for these people? How are they represented in this study?