Allegheny County’s adoption of assisted outpatient treatment, or AOT, has some mental health experts worried about coercion and overreliance on medication, but the county says it has safeguards in place and an advisory group in the works.
On Jan. 1, the county implemented the controversial legal tool for involuntary mental health care in the community — a decision that was sharply criticized by advocates, including one who called it “carceral.” County officials, though, said the program’s goal is to decarcerate people with serious mental illness or keep them from entering the criminal legal system. They’re beginning to detail the mechanics of a process that hasn’t previously been used in the state.
Erin Dalton, director of the county’s Department of Human Services (ACDHS), wrote that “no one will be arrested or jailed for not following their treatment plan” in a Dec. 23 letter to Jennifer Smith, deputy secretary for the state’s Office of Mental Health and Substance Abuse Services.
During a group interview with Pittsburgh’s Public Source, Dalton and other county human services officials explained how the program will minimize contact with law enforcement: Instead of police officers taking a person into custody and transporting them to a health care facility — which is often what happens to those who are involuntarily hospitalized — a treatment team will hand-deliver a court summons to a person who is the subject of an AOT petition, or it will be mailed to them.
The county’s adoption of AOT is a victory for the law’s advocates — including some family members of people with serious mental illness — who had long pushed for more forceful intervention to help those who resist treatment before they reach a crisis point. But a local researcher, whose team interviewed AOT recipients in large-scale studies, is worried about the impact of more involuntary intervention, even if it takes place in the community. She is skeptical of the county’s contention that AOT can be implemented without leading to arrests of people with serious mental illness.
“It’s playing with words in a way,” said Nev Jones, an associate professor of social work at the University of Pittsburgh.
Though AOT is a civil procedure, it has become intertwined with the criminal legal system in other states. In some jurisdictions, people under AOT orders can be arrested if their treatment plan is a condition of parole, she said. And regardless of a person’s criminal legal involvement, courts in Pennsylvania can order an involuntary emergency examination if they don’t adhere to their treatment plan, which may be enforced by police.
Public Source’s series “When care is compulsory” detailed the debate over AOT and the county’s consideration of this legal tool over the past year. Here’s what county officials and observers are saying now that implementation has started.
What is AOT?
AOT is a legal mechanism for involuntarily treating people with serious mental illness without hospitalizing them.
The law states “any responsible party” 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 psychiatric medication, but can also include therapy and other wraparound services. The statute bars courts from holding someone in contempt or issuing penalties for not following their treatment plan, which makes the law difficult to enforce. Some experts called it “toothless.”
Forty-nine states have AOT statutes on their books. New York was the first and implemented Kendra’s Law more than 25 years ago. Massachusetts — where an AOT bill was recently introduced to the state legislature — and the District of Columbia are the only holdouts.
Local research and national pressure
In a paper published in July, a team of researchers — including one based at the county’s Department of Human Services — established a causal link between involuntary mental health hospitalizations, or 302s, in Allegheny County and harm a person experiences after they’re discharged, including being charged with a violent crime and dying of suicide or overdose. Human services officials said that harm played a significant role in their decision to implement AOT as an alternative.
“We’ve concluded that the risks of doing nothing are higher than the risk of trying this, and [I] think we’ve put a number of safeguards in place” to mitigate the harm that involuntary treatment can cause, Dalton said.
Jones said she’s “not surprised” by the county’s decision to implement the law after opting out in previous years. She pointed to a nationwide shift toward strengthening involuntary mental health practices, compounded by an executive order issued by President Donald Trump in July that aims to institutionalize unhoused people who have mental illnesses, substance use disorders, or both.
“It’s not only inevitable here, but inevitable across the country at this point” due to the Trump administration’s efforts to “further both carrot and stick when it comes to their strategy around AOT,” said Jones, who was awarded a contract by the New York state legislature to co-lead an evaluation of that state’s AOT program. “So even a county or state that didn’t particularly want to do it at this point in time would be under additional pressure.”
How an AOT process would start
Human services officials said the AOT legal process will differ from that for involuntary hospitalization.
The initial court summons for a hold under Section 302 of the Mental Health Procedures Act, applicable when someone poses a danger to themself or others, is often delivered by police, said Michael Rocco, manager of county Information, Referrals and Emergency Services, which authorizes 302 petitions that weren’t filed by a doctor or law enforcement officer. But an official summons for an AOT hearing will be sent by mail and possibly also hand-delivered by a treatment team member, Rocco said during the group interview. “So it really doesn’t involve law enforcement at all,” he added.
Dalton wrote to the state that “people’s first engagement with AOT will be a peer, service coordinator or another trusted person” rather than law enforcement.
Collins said that in the case of unhoused people, who may not trust “the system,” the department will work with its street outreach partners who may have knowledge of the person. Those street outreach workers would be part of a process she called “case conferencing,” an initial effort “to figure out what’s the best approach for this individual.”
Jones pointed out that housing placements are built into AOT programs in other jurisdictions. If an unhoused person is guaranteed a housing placement under an AOT order, “then of course it is going to help them,” said Jones, noting “you could just as easily prioritize those same people without an AOT order.”
An ACDHS spokesperson wrote in an email that the county is assembling a team that will support the AOT process here. That includes:
- Rocco, whose team is on call 24/7 to authorize and arrange 302s and would also assist AOT petitioners
- AOT Coordinator Cindy Simpson, who has 20 years of mental health services experience and will coordinate case conferencing and collaboration among the courts, treatment team members and other stakeholders
- An unidentified psychiatrist from Centurion Health, a Virginia-based firm that provides correctional health care services across the country and operates the county’s mobile competency restoration team, which serves people found not competent to stand trial
- A “dedicated service coordinator” assigned to each AOT recipient and provided by the Human Services Administration Organization, a nonprofit with offices in Carrick and the North Hills that coordinates services for county residents facing court procedures.
Concern about arrests remains
If a person ordered to follow an outpatient treatment plan doesn’t comply, the court can issue a warrant for examination under Section 302. While a 302 petition isn’t a criminal procedure, it often involves contact with law enforcement, who may physically take a person into custody and transport them to a hospital.
A New York public defender told Public Source last year that those facing an AOT petition while also facing criminal charges are often compelled to comply with their court-ordered treatment plan as part of a plea deal. “There is a coercive element to that,” said Katherine Bajuk, a senior trial attorney and mental health specialist at New York County Defender Services, who represents people facing criminal charges in Manhattan.
Jones said AOT orders in New York can also become a condition of parole. “The nuance is that, technically, you’re not being arrested because of the AOT violation. You’re technically then being arrested because of the parole violation,” such as failure to comply with treatment, she added.
Dalton acknowledged that a person facing an AOT order here could face law enforcement in relation to “things that are happening in escalation,” such as a 911 call made by a petitioner.
An official from the county’s Office of the Public Defender, which will represent those facing AOT petitions, said strict confidentiality laws protecting patients’ mental health information will be the most impactful guardrail during court proceedings.
Information “should not be fluid between judges and divisions, whether or not someone’s under an AOT order,” said Sarah Linder Marx, the office’s senior deputy director of public outreach and staff development. “Unless the patient expressly waives their confidentiality for a purpose,” such as disclosing their AOT treatment plan to a judge to help their criminal case.
Dalton said Judge Hugh McGough, who serves in the Orphans’ Court division of the county’s Court of Common Pleas, will preside over AOT hearings.
During an interview, McGough emphasized the separation between AOT proceedings and those taking place in a specialty mental health court in the criminal division, which is overseen by Judge Beth Lazarra. He said the Orphans’ Court has “lined up an excellent team of communicators who will assure” that people facing AOT petitions are heard during the process. We “have a lot of experience listening to and hearing people’s problems, and helping them see their way through those problems with appropriate support.”
AOT and medication
Jones, a member of the county’s Mental Health/Intellectual Disability Advisory Board, said that compelling those under an AOT order to take medication is one of the county’s main goals. That’s typical of most AOT programs across the country, she added.
“It’s a very, very biomedicalized view of recovery, of people’s healing processes,” she said, noting the county is also piloting a program to test the efficacy of financially incentivizing people to adhere to psychiatric medication in the form of long-acting injectables.
“How aware are they of the substantial number of people who do not respond to antipsychotics?” Jones asked, explaining that a significant portion of people respond moderately or don’t respond at all to antipsychotic medication. Many also experience intolerable side effects and stop using the drugs.
Pim Welle, chief data scientist at ACDHS, emphasized the county’s understanding that medication doesn’t work for everyone or is “not worth it” due to the side effects. “Medication would never be given in [the] absence of a strong wraparound treatment team that’s trying to engage with the person,” he said. Welle said the treatment team will also work with the person to determine which medication side effects are tolerable and which are not, seeking a balance that stabilizes them and leads to long-term treatment.
Study and safeguards
The scientific literature on AOT is mixed. Those who support AOT point to research showing it improves outcomes for people with serious mental illness, while others point to research showing it provides little to no benefit.
Officials were motivated to act by “people’s calls for something” short of the 302 process, said Dalton. They don’t want “to wait and watch their loved ones decompensate in that way or wait for something more challenging to happen.”
Ruth Johnston of Richland 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 in a state prison that has a mental health unit — an outcome that outpatient commitment might have prevented, she said. (Though people with mental illness are disproportionately criminalized, research shows they’re more likely to be the victim of a violent crime than the perpetrator.)
“I’m thrilled that they are planning to implement [AOT],” said Johnston during an interview in May.
An official from Light of Life Rescue Mission, a Christian charity that contracts with the county to provide emergency shelter to the unhoused, told Public Source via email that he’s pleased the county is using “an effective and needed tool in [its] toolbox to serve those who are incapable of rendering self-care.
“Too often, suffering neighbors are left in our streets in psychotic crisis, in severe weather, or other life-threatening conditions because they are unable to recognize their need for help,” said Jerrel Gilliam, the nonprofit’s executive director, who worked for more than two years to bring AOT here.
The county’s exploration of AOT last year triggered outcry from the law’s critics, including clinical, legal and academic experts who said involuntary care can destroy a patient’s trust in the public mental health system and has serious implications for the civil rights and individual autonomy of some of the most vulnerable people in the county. They also pointed out that involuntary treatment disproportionately impacts Black people and other people of color, which is borne out in the county’s own 302 data. A report published last year by New York Lawyers for the Public Interest — which opposes AOT — found that 38% of current involuntary outpatient commitment orders involved Black people, who make up only about 18% of the state’s population.
Reactions to county’s AOT intentions vary
The county’s announcement follows a lengthy stakeholder engagement process, driven in part by a Public Source investigation this year of involuntary treatment here and in other jurisdictions. The county also consulted with officials from other jurisdictions with existing AOT programs, including those in California and New York state.
Confirmed AOT advisory group members
- Two people with lived experience to be selected by NAMI Keystone PA
- Susan Coyle, chief executive officer, Chartiers Center
- Betsy Farmer, dean, University of Pittsburgh School of Social Work
- Jerrel Gilliam, executive director, Light of Life Rescue Mission
- Nev Jones, associate professor, University of Pittsburgh School of Social Work
- Autumn Redcross, founding director, Abolitionist Law Center Court Watch Program
- Frederick Thieman, former U.S. Attorney of the Western District of Pennsylvania (1993-1997)
- Dale Verchick, director of public policy, Disability Rights Pennsylvania
- A psychiatrist who has not yet been selected
In a May letter, nearly 80 people — including county residents, Jones and other experts across the country — urged County Executive Sara Innamorato and County Council members to “challenge” the Department of Human Services’ intention to implement AOT and demanded “robust transparency and accountability, including third-party evaluation … and engagement with those directly impacted” if implementation moved forward.
Dalton told Public Source that starting this month the county will work with a research team based in New York to “do a more full assessment of our system of care for the seriously mentally ill.” Without going into details about that process, she said her team looks forward to the recommendations that come out of that assessment.
The county will also establish an advisory group to monitor implementation and review progress through 2026, according to the letter. Confirmed members include Jones and another academic expert, Gilliam of Light of Life, a former U.S. Attorney for the Western District of Pennsylvania, the director of a local court watch program, an unidentified psychiatrist and a disability rights attorney. The group will also include two people with lived experience selected by the National Alliance on Mental Illness (NAMI) Keystone Pennsylvania — the Pittsburgh-based state affiliate of the national parent organization.
Jones is “happy that there is an advisory board,” calling it an improvement over the “zero transparency” in the process so far.
Gilliam wrote it’s important “that AOT has clear oversight and accountability to ensure safe and just treatment for all.”
The advisory group’s meetings won’t be open to the public due to patient confidentiality laws, Rocco said. As of December, ACDHS had not finalized the group’s meeting schedule or determined what kind of program data would be shared with members. Dalton said she and other officials are considering providing data to the group on a quarterly basis, possibly under non-disclosure agreements.
“So long as we have those protections in place, we will be an open book on how this is going,” Dalton said.
Venuri Siriwardane is the health and mental health reporter at Pittsburgh’s Public Source. She can be reached at venuri@publicsource.orgor on Bluesky @venuri.bsky.social.
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