Assisted Outpatient Treatment

Learn about court-ordered outpatient treatment designed for people with a history of non-adherence to SMI treatment. 

What is assisted outpatient treatment (AOT), and who is it designed to help? 

When someone with SMI is unable to recognize that they have a mental illness, they cannot voluntarily engage in mental health treatment. By providing services under a civil court order (involuntary treatment), assisted outpatient treatment (AOT) offers a pathway to recovery for those individuals and others who might struggle to follow a treatment plan for a range of reasons. 

Note that AOT is known by other names in some places. For example, Virginia and Tennessee refer to their involuntary outpatient services as mandatory outpatient treatment (MOT).  

How does AOT work? 

AOT is person-centered, individualized care that can motivate treatment adherence by helping a person connect treatment adherence to a better quality of life.  

AOT programs are collaborations between outpatient service agencies and county or circuit courts. The court, county, or provider agency may appoint an “AOT monitor” to track AOT participant treatment adherence and ensure the treatment provider is doing their part to engage the participant in services. Note that some programs might give a different name to this role or manage oversight through a different organizational structure. 

Treatment teams might also include therapists, prescribers, case managers, vocational specialists, housing specialists, peers, community engagement coordinators, and/or others, depending on the participant’s needs and local resources.  

What is the black robe effect? 

In some AOT programs, the judge assumes an active motivational role and presides at regular court check-in meetings. Because judges command respect from participants and providers, they may influence outcomes through a phenomenon called “the black robe effect.” Their orders hold both the participant and the treatment provider accountable. 

In AOT programs with less judicial involvement, the court order itself can similarly incentivize follow through, outreach, and ongoing participation to ensure that a person who has struggled with treatment adherence in the past can stay engaged in the treatment process. Many AOT participants are motivated to adhere to treatment because they don’t want to be hospitalized again if their mental health deteriorates. 

Why aren’t voluntary outpatient services enough? 

The most common reason people with SMI don’t seek or stick with treatment is anosognosia, a symptom present in at least half of people with SMI that includes psychosis. Adults with SMI and anosognosia often become dangerously unwell before treatment can be ordered because they see no reason to seek services. Their decisions seem rational to them. 

Anosognosia isn’t the only reason a person might need AOT to achieve stability and shift toward recovery. People with SMI can struggle to correctly perceive their symptoms or make connections between their lack of treatment and their day-to-day struggles. The mental health system is extremely complex, with many gaps for people to stumble over while also navigating illnesses with mood and thought symptoms. All these issues may make voluntary treatment difficult to access without the additional layer of court oversight. 

Here’s a way to talk about anosognosia and AOT:  

A voluntary outpatient program is not accessible to everyone who would benefit from it, and especially to someone with anosognosia if they are incapable of understanding that they are ill. Without assistance, they cannot recover enough to lead a self-determined life. 

Is AOT effective and evidence-based? 

Yes. When systematically implemented and adequately resourced, AOT can dramatically reduce hospitalization, criminalization, and other adverse outcomes for its target population, which is individuals with SMI who have a history of non-adherence to treatment.  

Non-adherence is the preferred term for describing the inability to stay the course of treatment. This terminology avoids suggesting that difficulties in treatment adherence are due to personal failures or intentional decisions, which is often not the case. AOT can reduce a range of harmful behaviors and improve participants’ sense of personal engagement in their treatment. Like any intervention, however, AOT does not work for everybody. 

When utilized successfully, AOT reduces the cost and strain to treatment systems struggling to serve individuals caught in the “SMI churn,” which refers to the sickest individuals cycling through hospitalizations, incarcerations, and homelessness. TAC provides a summary of key AOT data points. 

What happens when treatment is delayed? 

The average duration of untreated psychosis is 74 weeks (about a year and a half) in the U.S. This long period of untreated psychosis can lead to many negative effects, including the following: 

• Treatment response worsening.
• Diminished insight.
• Increased severity of symptoms.
• Neurotoxicity in the brain.

AOT can improve outcomes by compelling treatment over a longer period (usually six months to 1-2 years) while in a community setting that is much less restrictive than an inpatient facility. AOT also is designed to help a person with recovery in their community, setting them up for a successful transition toward a more self-directed life once stability is achieved.  

AOT may be step-up or step-down care 

In some places, a person might access AOT in the community if another service fails to meet the needs. For example, assertive community treatment (ACT) is a high level of voluntary outpatient service available in some communities. If ACT alone isn’t working, a provider team might step up to serve the client through an AOT order, working with a local court. This option can be a way of avoiding inpatient hospitalization if outpatient services with an added court order are sufficient to meet the person’s needs. Not every state’s law allows for AOT as a step-up service, however. 

AOT is more commonly a step-down program option after an involuntary hospitalization or incarceration and can be court-ordered as part of discharge or release planning. Care partners might advocate for AOT while a loved one is hospitalized or incarcerated, explaining the need for court assisted care because of a history of non-adherence due to lack of insight, for example. The time to begin talking about AOT is at admission, as a program may take several weeks to set up and there may be a waiting list. 

Can someone go to jail for violating an AOT order? 

In general, AOT is a civil court process without criminal penalties, although some state statutes allow contempt of court charges to be filed for non-adherence. If a client decompensates, the treatment team is responsible for outreach and engagement to support stabilization. An AOT judge can ensure that everyone is working to maintain collaborative relationships and full access to services.  

If outreach and engagement fail, the team may discuss hospitalization to help the client re-stabilize. The judge might order an emergency evaluation, invoking a community and state-specific process that could lead to hospitalization. Generally, the AOT order resumes upon discharge. Sometimes a person cycles through several rounds of hospitalizations and AOT renewals before lasting stability is achieved.  

Does every state have AOT? 

AOT is authorized by law in all but two states (Massachusetts and Connecticut). Click on your state from TAC’s U.S. map to look up the outpatient commitment law in your state.  

Having an authorizing law, however, doesn’t necessarily mean AOT is available. Most states have substantial implementation gaps due to a lack of programming, willpower, and general understanding about how AOT works. A program may be established in one part of the state without serving other parts of the state.  

The TAC AOT Learning Network (AOTLN) helps stakeholders promote and implement programs. TAC’s website has information about AOT implementation and ways to get involved as an AOT champion. Included is a link to look for an AOT program in your community that may be part of TAC’s AOT network.   

Is AOT the same thing as mental health court? 

No. Mental health court is a process for diverting a criminal case into a specialty docket to incentivize treatment compliance. To volunteer for this option, a criminal defendant must be found competent/fit to act in their own defense and must be well enough to follow court orders over time. If they successfully complete the program, the criminal case might be resolved without impacting their record. If they are unsuccessful, they might go back to jail or face fines or other criminal penalties. 

To be considered for mental health court, individuals may be asked to “acknowledge” their illness and often must plead guilty to charges. For a person with symptoms of anosognosia and psychosis, mental health court is often not accessible.  

In contrast, AOT is involuntary and a civil—not criminal—court process. A person doesn’t have to acknowledge their illness to participate, so it’s more accessible for someone with anosognosia. Enrollment in an AOT program can potentially prevent a person from arrest or incarceration by getting them established in treatment before symptoms escalate, thus acting as a powerful tool to prevent criminalization of mental illness.  

Could AOT be a diversion option out of the criminal system? 

Yes. A criminal defendant can be shifted out of the criminal legal system and into the civil courts so the focus can be on treatment instead of adjudication. TAC’s white paper, Dismiss Upon Civil Commitment with AOT, is available to help jurisdictions reimagine the process for those with SMI. In fact, since the criminal case is dismissed and the individual is transferred to a civil docket, this option is diversion from criminalization in the truest sense of the word.  

A resource for grassroots advocates 

At a national AOT symposium, TAC asked family caregivers what they want providers and other system stakeholders to know about their experiences. Their raw and honest answers led to development of an infographic and two-page document that can be shared with professionals implementing SMI treatment programs: What families need you to know: An open letter to AOT judges, providers, and others with jobs that serve people with severe mental illness.