Facts, fast.
In December, Allegheny County officials informed the Pennsylvania Department of Human Services of plans to implement the state’s law for assisted outpatient treatment [AOT] by Sept. 1.
The county Department of Human Services [ACDHS] took that step after analysis of its program for forced inpatient mental health care — known as 302 commitments — showed high rates of death, emergency room visits, and involvement with the criminal legal system following involuntary hospitalizations.
What is AOT?
AOT is a legal mechanism for involuntarily treating people with serious mental illness without hospitalizing them.
The law states “any responsible person” can file an AOT petition, which starts a civil court procedure.
During a hearing, a judge may order a person to undergo treatment in the community, potentially including medication, therapy and wraparound services. State law does not outline a penalty for not following the treatment plan.
Local implications
The county acknowledged mixed results among studies of AOT’s efficacy, but believes that with services, it can achieve better outcomes here. Court officials expressed support for the move. The Office of the Public Defender indicated that it is not staffed to represent people subject to AOT petitions, but said it would do so to the best of its ability.
If AOT is implemented here and results in court-ordered care by a mental health provider, it could be a first instance since state lawmakers voted in 2018 to loosen standards for court-ordered outpatient treatment, according to Disability Rights Pennsylvania.
The rationale for AOT
ACDHS officials said they consulted about a dozen psychiatrists and clinical psychologists across the country, court officials, disability rights advocates, peer specialists, families of people with serious mental illness and the Treatment Advocacy Center before moving toward implementation of AOT in the county. They also reviewed data on 302 commitments.
Involuntary hospitalizations affect more than 3,700 people each year, according to a 2023 ACDHS report. The county found that following commitments:
- 20% of patients died within five years after their first evaluation for hospitalization
- 23% were charged with a crime within five years of release
- 60% used an emergency room within one year of release.
Failure to use medication as prescribed is a key driver of forced hospitalization and other poor outcomes, county officials said.
Light of Life Rescue Mission, a Christian charity that contracts with the county to provide emergency shelter, has worked to bring AOT here for two years. Executive Director Rev. Jerrel Gilliam said his group is advocating for AOT because of “an uptick” in people experiencing mental health crises at Light of Life’s facilities, and a lack of results from inpatient commitments.
Experts, advocates divided on AOT
Nev Jones, an associate professor in the School of Social Work at the University of Pittsburgh, said the county’s rationale for AOT flies in the face of her research showing that involuntary hospitalizations can destroy a patient’s trust in the mental health care system, and said best practices for mitigating that harm don’t include more coercive tactics. Jones has a contract with New York state to study the impacts of AOT there.
She criticized the county for moving forward without developing a public stakeholder process that centers the voices of people with serious mental illness and lived experience of involuntary treatment.
Ruth Johnston of Richland, who started a campaign called AOT for Allegheny County, after her son killed his grandmother, said involuntary outpatient care is better than incarceration. She didn’t see the need for a public stakeholder process.
Courtney Bergen, the equal justice works fellow at Disability Rights Maryland, argued for elevating the opinions of psychologists, social workers and peers, who are closer than most psychiatrists to the daily lives of people with serious mental illness. Maryland passed AOT legislation last year, and now 48 states have made legal provision for involuntary outpatient treatment.
Flawed research, pivotal report
Most studies on AOT have been flawed because they studied its use in only one state, didn’t consider the patient’s perspective or didn’t have a control group, among other reasons detailed in a national survey of AOT programs.
Results have been mixed, with some showing little to no benefit, while others indicate lower hospitalization rates and other improvements in outcomes.
ACDHS was particularly swayed by an evaluation of a federal AOT grant program, published last year and showing improved outcomes.
Clarification (5/15/2025): Assisted outpatient treatment is not yet applicable in Allegheny County, which was unclear in part of a prior version of this story.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s health care reporting.
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