One source of AOT opposition is concerns about coercion or a restriction of individual liberties. AOT serves as a lightning rod for opposition to all forms of involuntary psychiatric treatment, despite AOT being no more coercive than conditional release or mental health courts—both of which are widely accepted.
Some common misconceptions include:
1) AOT is forced treatment infringing on civil liberties. This argument has been soundly rejected in the courts. In the 2004 case Matter of KL, the plaintiff challenged Kendra’s Law, arguing it authorized “forced treatment” without adequate due process. The New York Court of Appeals, widely regarded as a champion of civil liberties, unanimously held that AOT is not forced treatment. The court noted Kendra’s Law prohibits forcible administration of medicine and only allows re-hospitalization if the usual commitment criteria are met. Thus, the court found the law relies on “the compulsion generally felt by law abiding citizens to obey court directives,” not force.12
2) People will voluntarily seek help if we make psychiatric services more widely available. This ignores the key factor addressed by AOT—anosognosia. Approximately half of individuals with serious mental illness experience anosognosia, damage to the parts of the brain used to think about ourselves, confirmed by at least 20 studies.13 People who think nothing is wrong with them—the signature symptom of anosognosia—have no reason to seek treatment. It is simply illogical to assume system improvements will draw in these patients, and the experience of many communities unfortunately bears this out.
3) AOT drives patients away from seeking treatment. There is simply no defensible evidence that this is true. In fact, when individuals receiving AOT under Kendra’s Law in New York were asked, 81% said AOT had helped them get and stay well.14
4) Why spend resources on patients who don’t want to be treated when so many who do want to be treated are not getting services? Research shows that the population served by AOT disproportionately uses public resources. Consequently, research has found that mental health services, including voluntary services, can actually be expanded when AOT is used because of savings associated with decreased resource utilization by a small population.15 More broadly, addressing the outsized costs associated with high utilization is a growing concern for public health and policymakers.
AOT is here to stay, not as a cure-all but rather as another tool to help treat selected patients who are otherwise the most difficult to treat. Dr. Darold Treffert summarized the rationale for treatment approaches such as AOT nicely:
It is not “freedom” to be wandering the streets, severely mentally ill, deteriorating and getting warmth from a steam grate or food from a garbage can; that’s abandonment. And it is not “liberty” to be in a padded jail cell instead of a hospital, hallucinating and delusional, without treatment because that is all the law will allow.16
Dr. Torrey is a research psychiatrist who specializes in schizophrenia and bipolar disorder. He is Founder of the Treatment Advocacy Center and Associate Director of the Stanley Medical Research Institute, and he is Professor of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, MD. Mr. Snook is Executive Director of the Treatment Advocacy Center.
The authors report no conflicts of interest concerning the subject matter of this article.
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