Maximize Results in AOT

The obligations of respect and compassion extend to all members of the AOT team who interact with the participant. It begins with the clinical team members who work with the participant to develop the treatment plan. It is equally critical that participants receive compassion and respect from the court.

There is research to support the efficacy of AOT with varying levels of service intensity. Determinations of level of care should be made case-by-case, based on clinical needs, exactly as they would be in the absence of AOT. While medications and case management are at the heart of most AOT treatment plans, participants will ideally have access to other evidence-based treatments such as Individual Placement and Support (IPS), Integrated Dual Disorder Treatment (IDDT), and Cognitive Behavioral Therapy for Psychosis (CBT-p), to name a few. This is not to say that a mental health system must have all of these services in place before implementing AOT. The research associating AOT with improved treatment outcomes has examined programs with relatively robust treatment services in place but does not identify any particular treatment service as essential to such outcomes.

Some state AOT laws require a treatment plan to be presented to the court and incorporated into the AOT order, such that the order becomes not just a general directive to adhere to prescribed treatment, but a specific directive to adhere to the particular set of treatment services that have been identified as necessary to allow the participant to live safely in the community. The treatment plan should be a basic outline of services to be provided, the provider responsible for each such service and the participant’s responsibilities for adherence. It should be written so that minor changes recommended by the treatment team will not require court approval.

It is not unusual or alarming for an AOT participant to miss one or more scheduled appointments, or even to stop taking prescribed medication. This alone is not reason to revoke outpatient status. The treatment team should endeavor to assess the participant, either in person in the community, and/or through any collateral information available. If the participant is not clearly demonstrating changes in behavior consistent with previous signs or symptoms of decompensation, the team should review the case to determine new engagement strategies and modify the treatment plan accordingly. However, if the treatment team concludes that a more restrictive level of care must be considered, it should not hesitate to take action. The absence of sanctions in the AOT model should not be mistaken for an absence of consequence.

For most AOT participants, it seems clear from current data that the length of time in the program matters. This should not be surprising. The goal of AOT is to help a participant engage with the treatment team, develop therapeutic relationships and come to recognize the improvements to their quality of life. For a participant with a long history of disengagement, the process of gaining trust in the treatment system and finding value in treatment requires sufficient time to take root. As a guideline, AOT programs should seek to keep each participant under AOT for more than six months. The maximum length of each court order is a matter of state law and varies widely. Some states only permit an AOT order of 90 days or less. However, in nearly all states, AOT orders may be renewed an indefinite number of times, so long as the participant continues to meet statutory criteria. Clinical findings as to readiness, not the maximum court order length under state law, should drive a decision on whether to allow the AOT period to lapse.

The American Psychiatric Association (APA) recommends that AOT court orders include language to explicitly authorize a clinician to direct a law enforcement officer to pick up a participant who may be decompensating and transport them to a facility for evaluation. This facilitates rapid response to non-adherence, which is essential to effective practice of AOT. It is also true that every encounter between an armed officer and a vulnerable person with mental illness carries a risk of exacerbating the person’s distress or an even more tragic result. For this reason, AOT programs should avoid overreliance on law enforcement partners. When participants begin to show behavior changes that raise concerns of a relapse, a program should do everything it can to address the situation with increased clinical supports. Involuntary evaluation requiring law enforcement transportation should be the last resort.

AOT participants commonly transition between levels of care or even institutions during the period of commitment. It is incumbent upon the treatment team to ensure that when these changes happen, new providers are well informed of the participant’s treatment plan, especially the medications and any issues pertaining to risk of harm to self or others. The ultimate treatment transition occurs when the participant is ready to leave AOT and engage in voluntary treatment. If this requires transition to a new provider, a joint meeting among the participant, the case manager and the new provider is beneficial to maintain treatment engagement and continuity of care.

With the participant’s consent, including a family member or friend in the AOT process can promote positive outcomes. Families and other members of the participant’s support network can help explain the AOT program and emphasize the importance of treatment adherence. Family members and friends can be helpful contacts for the treatment team because they are often the first to notice signs of psychiatric deterioration and can bring concerns to the attention of the case manager before the situation becomes a crisis. Just as importantly, they tend to notice and appreciate a participant’s improvements and can provide positive reinforcement. The participant must be permitted to choose the family member(s) or friend(s) they find most helpful. Some might in fact undermine treatment adherence if their goals do not align with the participant’s or if they are not convinced of medication’s effectiveness in treating mental illness. If the influence of such a family member or friend seems unavoidable, the treatment team should consider whether outreach to them would be a worthwhile intervention.