Perhaps you’ve heard of Assisted Outpatient Treatment (AOT), or perhaps you have no idea what it is. This blog entry will give you an overview of what AOT is and what it isn’t. There is so much misinformation out there that I feel clarification is in order. Also, I want to state that AOT helps only a very small percentage of people who suffer from the most serious mental illnesses, like schizophrenia.

What is AOT?

Assisted Outpatient Treatment (AOT) is court-ordered treatment for people who have serious brain disorders. Currently, forty-six states in America have AOT laws on their books. Not all states use these laws, and many states have never funded the laws. The most well-known AOT laws are Kendra’s Law in New York state, and Laura’s Law, in California. These are similar to other states’ laws, yet they differ from each other in some ways.

Assisted Outpatient Laws became necessary due to a small percentage of people who are too ill to seek help for themselves. These people have serious mental illnesses and typically suffer from anosognosia, as well.

What is anosognosia?

Anosognosia is a symptom of schizophrenia and bipolar disorder. Over half of people diagnosed with schizophrenia and roughly 40% of people diagnosed with bipolar disorder experience anosognosia. Anosognosia is a medical term for lack of insight into illness. Patients who have had strokes and some patients with Alzheimer’s experience anosognosia. Anosognosia impairs awareness of the illness and hinders treatment. My family member lacks insight into his illness and truly believes that he has special powers, like telepathy. He believes he’s not ill because the spirits that torture him are real people and not imaginary. There is no way to convince him otherwise, just like there would be no way for me to convince you that you are actually an alien from another planet. Anosognosia makes the symptoms of schizophrenia incredibly real.

Primarily due to anosognosia, some people with schizophrenia are reluctant to seek treatment. Why would they, since they aren’t ill? These people are often off medication (they don’t believe they need it) and may be living on the streets. Some will be isolating in the back rooms of their parent’s home. There may also be paranoia, sometimes frighteningly so.

Patients who are so resistant to treatment due to these symptoms of their brain illness often get into trouble with the law. It’s typically for minor things like vandalism or panhandling. They may also end up repeatedly in psychiatric facilities. This revolving door or jail, home, hospital, home, streets, jail, etc, is not only costly from a fiscal standpoint, it also reduces the already low quality of life of the person suffering from illness.

Why are people allowed to refuse treatment?

You may wonder why people who are this ill can refuse treatment. It began in the 1950s, when thorazine was introduced as an amazing new medication for psychosis. For decades, people with serious mental illnesses were abandoned in asylums and often neglected. With the advent of thorazine, it was believed that these patients could be returned to their communities and live near their families. At the same time, President John F. Kennedy signed into law the Community Mental Health Act of 1963. The idea was to empty the asylums and provide care in community treatment facilities. Unfortunately, President Kennedy was assassinated two weeks after signing the Act into law. It was never properly funded.

Another thing that was happening in the sixties was a focus on human rights. There were marches for civil rights for blacks and women. The focus was on autonomy and having rights. Included in this focus on human rights was the right to be mentally ill. If you were an adult, no matter how ill, you have the right to decide your course of treatment and whether or not to receive treatment. Many view this as inhumane for those who are too ill to make rational choices. The government does have a right and responsibility to protect citizens who are too ill. The doctrine of parens patriaie allows the government to step in and care for citizens who can’t care for themselves, typically due to disability or incapacitation.

In allowing these civil rights, society has neglected the care some people need. In moving people out of asylums and not properly establishing community care, many people fall through the cracks of the system. These are the people who need AOT.

How does AOT work?

In order to qualify for AOT, a person must have had several hospitalizations and/or incarcerations over a period of several years, or they must have a demonstrated history of dangerousness. They must also be determined to be able to benefit from AOT. This standard is very narrow, so as to not remove the rights of those who don’t need AOT.

Typically, a referral is made by a family member or other concerned individual. The referral is reviewed by the county and the process begins. It’s a slow, gentle process. Many attempts are made to engage the individual in treatment. A member of an Assertive Community Treatment (ACT) team will try to locate the person who has been referred. The first few contacts are to break the ice and engage the person. As these meetings progress, the hope is that the person will soon engage voluntarily.

If several attempts have been made and the person is still resistant to treatment, an order may be filed with the court. A court date will be set and the hearing will be in a conference room. It’s a civil hearing, not criminal, so it’s fairly relaxed. The subject of the AOT petition will be provided with legal representation to make sure his rights are not violated. The treatment team will attend and there will be a judge. Everyone there is invested in helping the person succeed. At this point, it’s still a voluntary option for the person to engage in treatment. As time goes on, if there is still no real engagement, the court can order the person to participate in treatment. The amazing thing about this is something called the “Black Robe Effect”. There is something about the authority of a judge that has an impact on even the most ill person. They tend to want to please the judge and follow through with treatment.

AOT reduces:

  • Hospitalization
  • Homelessness
  • Arrests and incarcerations
  • Violence, crime, and victimization

AOT improves:

  • Treatment compliance
  • Caregiver stress level
  • Quality of life for the patient

AOT isn’t for everyone. It’s just a small slice of the array of treatment possibilities. It is treatment that can and does help the most severely ill. But AOT is only as good as the commitment made by the treatment providers. I’ve heard it said that rather having the patient commit to the system, AOT requires the system to commit to the patient.

For more information on AOT, please go to the Treatment Advocacy Center website:

I hope this information is helpful to you. Please comment with questions, suggestions or other information. For information about how to receive caregiver-centric support, stress-management, and disease-specific tips and techniques (from the convenience and privacy of your own home via telehealth), visit MyHealios.