1. The Untapped Power of Assisted Outpatient Treatment (AOT) Laws
National College of Probate Judges
2018 Spring Conference
San Diego, CA
May 3, 2018
By:
Brian Stettin
Policy Director
Treatment Advocacy Center
treatmentadvocacycenter.org

2. Public Mental Health: Many Needs, No Single “Cure-All”
More investment in community-based care (mobile crisis teams, crisis respite, et. al.)
Inpatient psychiatric beds
Recruit mental health professionals to underserved regions
New law-enforcement / diversion strategies
Address treatment non-engagement

3. Treatment Non-Engagement
Too many with SMI caught in the “revolving doors” of the mental health and criminal justice systems

4. Many reasons for non-engagement
Inadequate community-based support
Health insurance gaps
Distance to provider / lack of transportation
Substance abuse
Side effects of medications
Challenges with executive functioning
Mistrust of doctors
Anosognosia / lack of insight

5. A most challenging cause of non-engagement:
a symptom of brain
dysfunction known as …
ANOSOGNOSIA

6. Anosognosia
Lack of insight into one’s own illness. (inability to recognize illness in self)
NOT denial
Brain-based. Out of the individual’s control
Makes non-adherence logical

8. Linking Anosognosia and Non-Adherence
Psych. Services 2/06:
Of 300 patients with non-adherence tracked, 32% found to lack insight.
Those 32% had significantly longer non-adherent episodes, more likely to completely cease meds, have severe symptoms, be hospitalized

9. Bottom Line on Anosognosia
If you build it …
… SOME still won’t come!

10. AOT is … A strategy to address non-adherence
A form of civil commitment
A means of leveraging the power of courts to influence behavior

11. Why Does the Court Order Matter?
As court orders go, AOT order is uniquely toothless:
No contempt of court
No forcibly administered meds
Fair to ask: what’s the point?

12. Point #1: “The Black Robe Effect”
Judges naturally command respect as symbols of authority in our civic culture.
The AOT judge must embrace the role of primary motivator.
The black robe effect works on the treatment system too.

13. Point #2: Rapid Response to Non-Adherence
Lack of punishment for non-adherence doesn’t mean lack of consequence

14. AOT “Program”? Where’s that in the law?
Answer: nowhere
Establishing a “program” means using the authority granted in the law to seek AOT, in a manner not contemplated by (but clearly consistent with) the law.

15. AOT is not Mental Health Court
Court’s authority is not predicated on the commission of crime.
Must be heard in court with jurisdiction over civil commitments. (In many states, that’s Probate Court.)
No “sanctions” for violating the order.
Should not require the individual’s voluntary choice to participate.

16. AOT is not just for those presently refusing treatment
Legal criteria allow programs to choose patients based on history and fragility of condition, not immediate state of mind.
Most natural point to start AOT is upon hospital discharge of a stabilized patient
Starting AOT with positive outlook is optimal.
“Voluntary” settlement agreements are fine, but …

17. Judicial involvement in every case
Any settlement agreement should require court approval.
Lack of need for a contested hearing is no reason to deny patient the benefits of interacting with the judge.

18. Periodic Status Conferences
The best AOT judges check in regularly with the parties. Convene all around a table.
Stresses that AOT is a reciprocal commitment, not one-sided.
Regularly reinforces the “black robe effect” upon both sides.

19. [video break #1]

20. Recovery Model vs. Medical Model
AOT is not an outright rejection of the Recovery Model; it is a rejection of Recovery Model extremism.
The goal is to maximize self-direction while acknowledging that SOME patients, at CERTAIN TIMES, have a limited capacity for it.

21. [video break #2]

22. “How’s that workin’ for ya?”
8 months in living hell (hunger, cold, filth)
8 months of potentially irreversible damage to brain
8 months daily exposure to life-threatening hazards (OD, violence)
God-knows-what done to raise survival money (violent crime, prostitution)
Needless to say, Steve sees none of this.

23. He could die. Well, that’s alright, that’s his choice.
NO, IT ISN’T “CHOICE.”

24. NO, WE DON’T HAVE THE LUXURY OF “TIME”
We have to give people not only choices, but also time to make those choices.
NO, WE DON’T HAVE THE LUXURY OF “TIME”

25. We Have the Data! Asssted Outpatient Treatment
Final Report on the Status of
Asssted
Outpatient
Treatment
New York State
George E. Pataki, Governor
Office of Mental Health
Sharon E. Carpinello, R.N., Ph.D., Commissioner
March 2005

26. 2009 NY Study: AOT Works 2009 NY study results (Duke et. al.):
Likelihood of hospital admission over 6-month period cut in half (74% to 36%)
“Substantial reductions” in hosp days
Likelihood of arrest over 1-month period cut in half (3.7% to 1.9%)
AOT group 4x less likely to commit serious violence than non-eligible control group, despite more violent histories

27. 2009 NY Study: Fears Unfounded
AOT recipients no more likely to feel coerced by mental health system
AOT recipients report no greater sense of stigma
Impact on quality of voluntary services was POSITIVE

28. 2013 NY Study: AOT Saves Money!
In NYC, net treatment costs declined 43% Y1, another 13% in Y2.

30. TAC is Here to Help
Brian Stettin Policy Director