Assisted Outpatient Treatment: Let’s ‘Assist’ Patients By Forcing Them

Assisted outpatient treatment (AOT) is a marketing term for involuntary commitment, but in an outpatient setting. AOT is like putting lipstick on a pig and calling her a princess. Experts on AOT sometimes like to pretend AOT is something different than forced treatment:

“Forcing [a person] to take medication is assisting him to make the choice we think he would make if he had a normally functioning brain.”
~ E. Fuller Torrey, MD & Jonathan Stanley, JD

Let’s delve into the twisted logic here of assisted outpatient treatment.

In the rest of the world, researchers call forced outpatient treatment by its proper name — involuntary outpatient treatment (IOT). Torrey & Stanley’s (2013) reasoning that assisted outpatient treatment (AOT) isn’t “forced” apparently is because people who are in AOT don’t have the necessary insight into their behavior and disorder in order to make a rational decision on their own:

Most individuals with serious mental illness on assisted outpatient treatment have anosognosia.

There’s no research reference attributed to this statement, because there’s actually no data (that I could find anyways) that would support such a conclusion. In fact, I could find no large-scale survey or study conducted on the characteristics of people who are committed via involuntary outpatient commitment laws.

Now, let’s say they have some data I couldn’t find or don’t have access to. What is anosognosia? Traditionally, the term has been used to describe the lack of awareness a patient might suffer from after having a brain injury or stroke. In other words, it’s caused by a physical alteration of your brain.

It is also sometimes used, although significantly less often, in the context of psychiatric disorders to describe a patient’s lack of insight into their disorder. Usually we just say a patient lacks insight. Lacking insight is not a disorder, however, nor is it a recognized symptom of most mental illness diagnoses. Many, many people in outpatient psychotherapy lack insight into their disorder.

“Lacking insight” into your disorder isn’t evidence that your brain is somehow dysfunctional or organically impaired. Despite decades’ worth of research, we still don’t know what a “normally functioning brain” looks like. Understanding the underlying mechanisms of how the brain actually works is still very much in its infancy.

Claiming some sort of brain differentiation — with little scientific basis — is a pretty thin branch to hang one’s argument on. Especially when hundreds of thousands of people lack such insight and still do pretty well in their lives and ordinary voluntary outpatient treatment.

Assisted Outpatient Treatment Results

But you have to ask yourself the core, basic question to any treatment program — does it get results? That is, do people in AOT have better treatment outcomes for their mental illness than those who don’t enter such a program?

Strangely, a lot of the research on AOT looks at things that have nothing to do with helping a person get better. They look at re-arrest rates, cost of the program or treatment, or rates of crime — behavior that is rarely the focus of a person’s treatment.

One recent study of 184 patients in New York City might help shed some light on the answer. The study (Phelan et al, 2010) actually looked at a population of people in AOT and compared them with a control group of people who had been recently discharged from a psychiatric hospital and were attending the same outpatient facilities as the AOT group.

AOT did not help people get better than treatment as usual — both groups experienced similar reductions in psychotic symptoms.

What AOT also did is apparently helped reduce the risk of serious violent behavior. Someone in forced outpatient treatment was four times less likely to report an incident of serious violent behavior than those in the control group. ((As the researchers broadly defined it, however, “serious violent behavior” could also mean getting into a fight in a local bar.))

Sadly, however, this is not the last word on the topic. Because another robust study on AOT called the Duke Mental Health Study (Swanson et al., 2000) found little support that forced outpatient commitment alone reduced violence. Instead, they found that improved outcomes and reduced violence was associated with simply more frequent service visits over an extended period of time (6 months or more).

Which comes as no surprise to most mental health clinicians who regularly work with people with schizophrenia or bipolar disorder, the primary diagnoses involved in involuntary outpatient treatment. Frequent treatment appointments help keep a person connected to their services, such as psychotherapy. That’s why day treatment programs can be so effective — a person has someplace they can go every day with a comfortable and familiar regiment.

To this day, research is mixed on the effectiveness of AOT. It doesn’t appear to be more effective than standard treatment in treating a person’s psychiatric disorder — the primary purpose of anything with the word “treatment” in its name. And a reduction of violent behavior can likely be achieved by less coercive means — by simply providing adequate treatment programs that people can partake in on a daily or weekly basis.

There may be a place for involuntary outpatient treatment in our society. But the evidence doesn’t clearly show they work, or that less coercive measures wouldn’t achieve the same effects.

In fact, if you’re involved in the criminal system because of your mental illness, a mental health court is perceived to be less coercive (Munetz et al., 2013), demonstrating the rich diversity of treatment efforts we should embrace. Because we went down this road once before, putting all of our eggs into the involuntary inpatient treatment approach. And we know how well that worked out.

References

Munetz, MR et al. (2013). Mental health court and assisted outpatient treatment: Perceived coercion, procedural justice, and program impact. Psychiatric Services in Advance. doi: 10.1176/appi.ps.002642012

Phelan, JC et al. (2010). Effectiveness and outcomes of assisted outpatient treatment in New York State. Psychiatric Services, 61, 137-143.

Swanson JW, Swartz MS, Borum R, et al. (2000). Involuntary out-patient commitment and reduction of violent behavior in persons with severe mental illness. British Journal of Psychiatry, 176, 324 — 331.

Torrey, EF & Stanley, J. (2013). “Assisted Outpatient Treatment”: An Example of Newspeak?: In Reply
Psychiatric Services, 64, 1179-1180. doi: 10.1176/appi.ps.641109