When care is compulsory
Allegheny County’s 302s, the push for AOT and the debate over involuntary treatment
After years of opting out, Allegheny County could soon adopt a controversial type of involuntary mental health treatment that takes place in the community instead of a hospital. The move sparked joy among some local advocates, who have long decried “dangerousness” as a standard for commitment, and fury among others, who point to the harms caused by forced psychiatric care.
In December, county officials quietly informed the Pennsylvania Department of Human Services of their plan to implement the state’s law for assisted outpatient treatment [AOT] by Sept. 1.
In a letter, Erin Dalton, director of the county’s Department of Human Services [ACDHS], described a “strong demand for a ‘step-down’ option from incarceration and involuntary hospitalization.” The county’s analysis of its program for forced inpatient care — known as 302 commitments — showed poor outcomes following discharge from a hospital, including high rates of death, emergency room visits, and involvement with the criminal legal system.
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, which typically includes medication, but can also include therapy and wraparound services. State law bars courts from holding someone in contempt or issuing penalties for not following their treatment plan.
While the county “grappled” with “mixed results” among studies of AOT’s efficacy, it believes “the law may improve” those poor outcomes if paired with robust services, Dalton wrote to Jennifer Smith, deputy secretary for the state’s Office of Mental Health and Substance Abuse Services [OMHSAS]. “We will implement AOT in 2025,” she wrote on a form that counties use to annually notify the state of their choice to opt out of the law, explaining the county needs time for “necessary planning” ahead of implementation. ACDHS provided the documents to PublicSource after this reporter’s inquiry.
Dalton hedged during a group interview this month that included multiple human services officials, telling PublicSource the county “is still in exploration” and considering “harms and benefits.”
“And so we haven’t decided to implement,” she added. “We’ve moved in the direction of thinking through how, if we did implement, whether we think it would improve outcomes.”
Newly confirmed mental health advisory board
Allegheny County recently appointed new members to its Mental Health/Intellectual Disabilities Advisory Board, which helps the county develop and implement services for residents. The appointments were confirmed by County Council April 8. Board meetings are virtual and open to public. Join the next meeting at 4:30 p.m. May 13 here.
If the county moves forward, its Office of the Public Defender will represent those facing AOT petitions in court, though one of its officials said the county had yet to commit additional resources to its overburdened staff. The official was surprised that Dalton said the county hadn’t made a decision.
“My understanding was that it was happening,” said Sarah Linder Marx, senior deputy director of public outreach and staff development, whose colleague in the public defender’s office met with Dalton’s team to discuss due process for those who are petitioned. “This is the first time I’m hearing that there may not be a completion to this project.”
Joe Asturi, the spokesperson for the county’s Court of Common Pleas, wrote in an email that the court is “pleased” to work with the county on AOT, describing a need for “more options” to help people with serious mental illness.
“The court plays an important role in implementing AOT, and we are in the early stages of setting up court processes to handle AOT cases,” he wrote. “We will be using existing resources in our behavioral assessment unit as needed.”
Local advocates sharply divided on AOT
The county’s move incensed a new member of its Mental Health/Intellectual Disabilities Advisory Board, who learned of the plan for AOT implementation from PublicSource. Nev Jones, an associate professor in the School of Social Work at the University of Pittsburgh, said she was kept in the dark by county officials, despite repeatedly offering them her expertise on psychosis interventions after she heard they were considering AOT last year.
“The logic of how they go from, ‘People don’t do well in our county after they’re involuntarily hospitalized’ to ‘what we need is AOT’ is just shocking to me,” said Jones, who was awarded a contract by 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.
Jones said the county’s rationale 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. “People describe just being absolutely traumatized and wanting nothing to do with a system that treats them that way. And the last thing that is going to reverse that erosion of trust is forcing people to [take medication] in the community,” she said.
An advocate who pushed the county to start AOT for years said she was “thrilled” to hear it may do so.
“Something bad is happening every day and you need to intervene to stop it,” said Ruth Johnston of Richland, who started a campaign called AOT for Allegheny County after her son, Levi Staver, who has schizophrenia, killed his grandmother while experiencing psychosis in 2013. He’s now incarcerated in a state prison that has a mental health unit — an outcome that outpatient commitment might have prevented, she said.
AOT “is the caring, neighborly way to take care of people,” she added, but she doesn’t support a public stakeholder process before the county implements it. “I am not wishing that the critics could be more involved.”
Ruth Johnston describes the day her son, Levi Staver, fatally stabbed his grandmother while experiencing psychosis, shows his drawings, and points to his childhood photo. She spoke in her Richland Township living room on May 7. Johnston believes AOT could have prevented her son from hearing the voices that told him to kill his grandmother. (Photo by Stephanie Strasburg/PublicSource)
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 uses literature from the Treatment Advocacy Center — a powerful advocacy group that promotes AOT nationwide — to inform his presentations about solutions to homelessness.
He said his group is advocating for AOT because of “an uptick” in people experiencing mental health crises at Light of Life’s facilities. He described “a cycle” that starts with police taking a person in crisis to UPMC Western Psychiatric Hospital or resolve Crisis Services.
“Within half an hour, they’re back on the street again,” he said. “When no one else is accepting them, they will drop them off to us. And so we become the safety net.”
Some people “can’t stay in our facility because they’re so unstable,” he continued. “… So as a loving community or as people that are good neighbors here in Pittsburgh, how do we help that person? And so that’s where AOT comes in.”
If AOT is implemented here and results in court-ordered care by a mental health provider, it could be a first since state lawmakers voted in 2018 to loosen standards for court-ordered outpatient treatment. An attorney at Disability Rights Pennsylvania who tracks implementation said she’s not aware of any successful efforts, noting the few counties that tried faced significant fiscal and administrative challenges.
The ‘quest’ that could lead to AOT implementation
Dalton said her team is on a “quest” to better serve people who are at risk of being involuntarily hospitalized.
Along the way, 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. Those conversations led them to believe AOT could be part of the solution to a broken system for 302 commitments.
Involuntary hospitalizations affect more than 3,700 people each year, according to a 2023 ACDHS report. Among other adverse outcomes, the county found:
- 20% 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.
“So those poor outcomes without any treatment and follow-up are quite likely to continue,” said Michael Rocco, manager of county Information, Referrals and Emergency Services, which authorizes 302 petitions that weren’t filed by a doctor or police officer. AOT would allow “follow-up that’s a little more structured,” which he said would “hopefully tighten up that connection between inpatient and outpatient treatment so that they’re not getting lost in that area.”
County officials emphasized the importance of making sure people take their medication as prescribed. In her letter to the state, Dalton cited research and county data showing medication non-adherence was “a leading pathway” to forced hospitalization and other poor outcomes. And Alex Jutca, director of the Office of Analytics, Technology and Planning, said it was “a consistent theme” across their conversations with stakeholders.
“One woman told me something like, ‘It took me eight years, three involuntary hospitalizations, being evicted, losing my relationship with my mother, to teach me that being on medication was super important,’” he said.
Asked how many people with lived experience of involuntary treatment they had consulted before moving toward implementation, Dalton said, “People don’t come to every meeting and disclose their behavioral health background, but we have plans that are on the books to talk with more folks with lived experience.
“I do think it’s important to have something concrete when talking to those folks about how this might change for them, and we simply aren’t there yet.”
Who has a seat at the table?
Disability rights experts and advocates sharply criticized the county’s approach to engaging those who would be impacted by AOT and questioned the diversity of expertise and viewpoints among those the county consulted.
Jones admonished the county for overlooking local experts like her, whose research is grounded in firsthand experience with both voluntary and involuntary treatment. In an essay for PublicSource, she described how being involuntarily hospitalized and facing stigma as a doctoral student with schizophrenia nearly derailed her academic career. She emphasized the need to involve people with lived experience and said the county would have needed to speak with around 100 people to truly capture the range of psychiatric perspectives.
Courtney Bergan, the equal justice works fellow at Disability Rights Maryland, argued for elevating the opinions of psychologists, social workers and peers. “They’re closer to people’s daily lives and their living conditions, and [can] give that kind of more qualitative information about what their needs might be and maybe why they’re not participating in treatment.”
Maryland passed AOT legislation last year.
Allegheny County human services officials said they met with patient advocates from the Disability Rights Network and the American Civil Liberties Union.
Brynne Madway, a staff attorney at Disability Rights Pennsylvania in Philadelphia, said her group believes the county should focus on “improving its services or the accessibility to its services,” instead of putting resources toward “creating judicial involvement in what is really someone’s personal health decision making.
“But it seems that they plan to forge ahead … although they remained open to future dialogue,” Madway added.
Dalton said the department has “talked to lots and lots of people. … We’re going to continue, both locally and nationally.”
A fierce debate over AOT’s effectiveness
The scientific literature on AOT is mixed. Some who support AOT point to research showing it improves outcomes for people with serious mental illness, while others who don’t support it point to research showing it provides little to no benefit.
Most studies were flawed because they studied AOT in only one state, didn’t consider the patient’s perspective or didn’t have a control group, among other reasons detailed in this national survey of AOT programs.
“It’s very hard to study this in a controlled way,” said Jones, describing how researchers are “battling each other over interpretation of the data.”
Dalton’s most recent letter to the state in December acknowledges these limitations in the evidence. In an earlier letter sent to the state in 2023, she wrote, “… My aim is to reduce harm and improve wellness for Allegheny County residents. It is not yet clear to me that AOT would advance this aim.”
Asked what made things clearer for her, Dalton brought up an evaluation of a federal AOT grant program, published last year by the U.S. Department of Health and Human Services. It showed AOT is associated with improved outcomes for patients in six states. But just because it “finds pretty solid results across varying jurisdictions does not mean that it is the only study on this and it obviously doesn’t include Pennsylvania,” she said.
Studies that found benefits showed lower hospitalization rates, a reduction in violent behavior and a higher quality of life.
Jones and other experts said such findings emerge because AOT often bumps people who are struggling with poverty or housing instability to the top of the list for services.
“Now the whole question is, would the same benefits accrue if it was voluntary?” she said. “If you were helping the person get housing that they wanted anyway, if you were helping the person get on benefits that they wanted and needed anyway?”
Venuri Siriwardane is PublicSource’s health and mental health reporter. She can be reached at venuri@publicsource.org or on Bluesky @venuri.bsky.social.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s health care reporting.
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