The Pennsylvania state seal in Harrisburg. File photo.
Allegheny County is on the brink of implementing a controversial type of involuntary mental health treatment, but it has few lessons to learn from other Pennsylvania counties.
The majority have opted out of implementing the state’s law for assisted outpatient treatment [AOT] — a legal mechanism for involuntarily providing treatment in the community, often including medication, to people with serious mental illness. County officials hope AOT will keep people out of hospitals and the criminal legal system, but some local experts say it strips people of their rights.
Advocates on both sides of the debate said they’re not aware of an AOT petition that resulted in court-ordered treatment in the state. The few counties that tried struggled with fiscal and administrative hurdles, said Brynne Madway, a staff attorney for Disability Rights Pennsylvania.
If Allegheny County succeeds at building a functioning system for AOT, it could be the first in Pennsylvania to do so since state lawmakers voted in 2018 to loosen standards for court-ordered outpatient treatment. Only Bucks and Dauphin counties didn’t opt out of providing AOT services this year, a spokesperson for the Pennsylvania Department of Human Services wrote in an email.
AOT implementation can vary significantly across counties and states. As of last year, 48 states had AOT statutes. Only Connecticut and Massachusetts don’t have AOT laws.
To understand the stakes as the county moves closer to implementation, PublicSource turned to experts, advocates, providers and people with serious mental illness who’ve had varying experiences of AOT in other states.
A tale of two AOT orders
Two people in neighboring states reported dramatically different experiences while under AOT orders.
Joseph, 56, is a graphic designer and artist in Buffalo, N.Y. PublicSource is withholding his full name to protect his privacy. He was diagnosed with schizophrenia in his 20s, which caused periods of psychosis and involuntary hospitalizations. He tried various medications voluntarily, but most didn’t work or caused debilitating side effects.
After he declined to keep taking one of those medications because he couldn’t bear the side effects, his psychiatrist successfully petitioned for AOT in 2006. The order was lifted three years later, but he was placed under another one in 2023.
He lives in supportive housing and is happy he has a home health aide because “it gives me someone to talk to.” He receives assertive community treatment [ACT] in his home — a model for delivering services in the community through an interdisciplinary team, and one of the options listed in Pennsylvania’s AOT statute.
A nurse on his ACT team shows up every two weeks to inject him with an antipsychotic. It mostly keeps his symptoms at bay, but he’d like to try a newer drug that he hopes will be more effective. He’s on Medicaid and his doctor said the drug is too expensive. He desperately wants therapy, but said his team hasn’t connected him with a therapist.
“I would just like to get … medication from an independent doctor [and see a] therapist. That’s it,” he said. “I don’t want to be under AOT.”
In Ohio, Bradley Tarr walked barefoot along Interstate 71 while in the middle of “this huge religious delusion of grandeur.” He was 19 and experiencing mania — a symptom of what he now knows to be schizoaffective disorder. He was 20 miles north of his home in Bellville and had developed thick calluses on his feet by the time he was picked up by highway patrol officers and delivered to his mother.
Tarr first developed symptoms when he was 11 and was misdiagnosed and prescribed the wrong medication for years. He didn’t get the right diagnosis until after he was placed under an AOT order at 26. He said the experience was “very positive” because his team was composed of what he believes are “the five essential members”: a psychiatrist and therapist who “deeply cared” about him, a case manager, a guardian ad litem and the judge.
His psychiatrist and therapist worked together to diagnose him and put him on the right medication regimen. And his guardian ad litem worked to get a disability discharge for his $35,000 in student debt.
Asked about civil liberties and what he thinks of the criticisms of AOT, he recalled his experience on the highway: “Was I in a place of actual liberty and actual freedom, or was I being shackled by the mental illness?” He noted he can only speak to his experience in Richland County, which he said is a model for other counties that want to implement AOT.
Now 32, he identifies as a “pro-AOT advocate” and regularly speaks at events for the Treatment Advocacy Center and the National Alliance on Mental Illness. The latter says it supports “involuntary civil commitment only when used as a last resort.” He disclosed that he receives modest stipends and speaking fees from the organizations.
What’s it like to work on an AOT team?
County officials said during an interview that they consulted a dozen psychiatrists and clinical psychologists before moving toward implementing AOT. UPMC declined to make its clinicians who may have advised the county available for interviews, including Jack Rozel, the medical director of resolve Crisis Services, a free emergency mental health service for county residents. The Allegheny Health Network didn’t make any clinicians available before deadline.
PublicSource spoke with two clinicians from outside of Pennsylvania who had experience treating AOT recipients.
Enrico Castillo, an associate professor of clinical psychiatry at the University of California Los Angeles, has treated AOT recipients in New York and L.A. He was part of an interdisciplinary ACT team in New York that traveled to patients in the community to provide services.
He said the best AOT services are “attuned” to the possibility that a patient “may have had very negative experiences with mental health treatment.” Providers should be “trained to give them a more positive experience in treatment” and should “spend a lot of time focusing on building the relationship.”
AOT also keeps providers from dropping patients if they don’t adhere to treatment, he added. “It forces the mental health provider to continue to follow up with the patient and I’ve seen that be very effective.”
The other clinician, Philip Yanos, is a professor of psychology at John Jay College of Criminal Justice. He’s a clinical psychologist who provides therapy and supervises trainees as part of an ACT team in Manhattan.
Yanos said his state’s AOT statute, enacted in 1999 and known as Kendra’s Law, was meant to prevent violence among a “very narrow sliver” of the population of people with serious mental illness. Now, “it’s basically being applied much more broadly for people who have a history of non-adherence with treatment,” in part because it’s “being used to make up for lack of access to evidence-based services.
“Who are we bringing into this [in a way that] it might harm their relationship with the mental health system?” he asked. “I’ve heard a lot of people we work with say, ‘As soon as I’m off AOT, I’m gone.’”
Venuri Siriwardane is PublicSource’s health and mental health reporter. She can be reached at [email protected] or on Bluesky @venuri.bsky.social.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s health care reporting.
