Assisted Outpatient Treatment in Los Angeles County: Implications for Involuntary Outpatient Services

Background and Purpose. Assisted Outpatient Treatment (AOT), also known as involuntary outpatient treatment, involves the provision of intensive mental health services and case management to high-risk individuals with serious mental illness (SMI). However, a unique feature of California AOT programs is that individuals can agree to services voluntarily after 30 days of outreach and engagement. AOT program eligibility criteria vary by state, but generally include histories of violence and suicidality and frequent hospitalizations or incarcerations. The effectiveness of these specialized involuntary programs to effectively target and enroll those with violent histories is understudied, and yet is critically important to their planning and implementation. The goals of this presentation are the following: a) explore quantitative rates and qualitative experiences of violence among those referred to AOT and their families, and b) examine quantitatively what factors predict whether individuals meet criteria for AOT and if they enroll.

Methods: Data were drawn from county program and administrative datasets, qualitative interviews with family members, and ethnographic observations. All 1302 referrals to Los Angeles County’s AOT from its inception in May 2015-January 2018 were evaluated. 64% (n = 830) were determined to meet criteria for AOT services and 377 enrolled in AOT. Twenty-four interviews with family members were completed. Descriptive analyses were completed of the rates of violence to self and others. Logistic regression was used to test whether risk factors associated with violence (being homeless, current substance use, age, gender, and race/ethnicity) were associated with whether participants met criteria for AOT and if participants enrolled in services. In the model where enrollment was the outcome, whether services were involuntary was also included as a predictor.

Results: Quantitative and qualitative data suggest high rates of violence to self and others by those referred to AOT. Official records of acts of violence to self and others before enrollment were recorded only as of May 2016. Of the 514 persons for whom this data is available: 49% had at least one act of self-harm. For violence to others, among the 668 with data, 77% had least one instance of harm to others. Qualitative data suggest very high levels of violent victimization by both AOT referred persons and their families, including high rates of self-injury and interpersonal violence (especially against family members).  Family members described safety concerns and reported several strategies employed to manage their safety, which interfered with their quality of life (locking bedroom doors at night, moving to an unknown location). Involuntary treatment was ordered for 61 individuals. In a logistic regression model of whether or not individuals met criteria for AOT, those who were younger (OR=.99), homeless (OR=.75), or whose race/ethnicity was other (OR=.20; reference group: Whites) were all less likely to meet criteria. Individuals currently using substances were more likely to meet criteria (OR= 1.40). In a logistic regression, among those assigned a provider, only involuntary status predicted enrollment in services (OR=2.31).

Conclusions and Implications: Violence to self and others are central issues for individuals who are referred for involuntary outpatient mental health treatment.