Debates over Assisted Outpatient Treatment (AOT) too often ask us to choose a side. Either we respect autonomy and rely exclusively on voluntary treatment, or we accept coercion as necessary to ensure people receive care. Neither position adequately reflects the complexity of serious mental illness — or of human beings themselves.
Voluntary treatment should always be the preferred path. But there are people for whom even well-resourced voluntary services have not been enough to sustain recovery. AOT is intended to address that much narrower circumstance. This distinction matters when evaluating outcomes: the success of voluntary treatment for those able to remain engaged in it does not necessarily tell us what will work for someone who has repeatedly struggled to do so.
In June 2026, New York State released an independent evaluation of its AOT program. The evaluation examined outcomes, implementation, participant experiences, and comparisons with intensive voluntary services. That comparison is particularly important: if voluntary treatment can achieve the same outcomes for the same people, the justification for a court order becomes considerably harder to make.
The findings were more complicated. Across ten key outcome measures, people receiving AOT had significantly better outcomes than a voluntary Assertive Community Treatment (ACT) comparison group on four measures. The voluntary ACT group performed better on two, while four showed no statistically significant difference. The evaluators viewed the strong results among voluntary ACT participants as evidence that New York has room to make greater use of voluntary intensive treatment where appropriate.
That strengthens the case for making robust voluntary services readily available and ensuring that people being considered for AOT understand those alternatives. But it does not make the two approaches — or the people receiving them — interchangeable.
Earlier New York research has also found reductions in hospitalization and improvements in treatment engagement while individuals were receiving AOT. These findings should not be interpreted to mean that a court order alone produces recovery. Under New York’s AOT program, court-ordered treatment includes care management or ACT services, along with other services identified in an individual treatment plan. These may include medication, therapy, substance use treatment, educational or vocational activities, and other supports. Separating the effect of these services from the mandate itself is difficult.
We should aggressively invest in intensive voluntary services and make them accessible long before court intervention is considered. But their success for many people should not lead us to assume they will be sufficient for everyone.
What do we owe a person when meaningful voluntary treatment is genuinely available, efforts at engagement have been made, and their illness nevertheless repeatedly prevents them from using those services successfully?
It is tempting to frame the answer entirely around individual autonomy. If each of us lived in a vacuum, perhaps the equation would be that simple. We do not. We live in families and communities, and the effects of serious illness that remains inadequately treated can extend beyond one individual.
Children deserve particular consideration. They have little control over their circumstances and often little ability to understand or change what is happening around them. I know this not only through my professional work, but through lived experience as a child in a family profoundly affected by serious mental illness. The effects of trauma do not necessarily disappear when a crisis ends. They can reverberate through families and across generations.
This does not give families an unlimited claim over another person’s treatment decisions, nor does family hardship alone justify coercive treatment. But neither should our concern for one individual’s autonomy make everyone else in the equation invisible.
Choosing not to intervene does not necessarily mean that coercion disappears. Sometimes it means waiting until circumstances deteriorate enough for another system to intervene — perhaps through emergency hospitalization, child protective services, or the justice system. Those interventions can be considerably more disruptive to the individual and their family.
The ethical question cannot be limited to the consequences of intervention. We also have to consider the consequences of choosing not to intervene when voluntary treatment has repeatedly been insufficient.
None of this means AOT should become an easy answer. Quite the opposite. Its narrow application is part of what makes it defensible. Gross expansion carries serious risks. AOT should never become a mechanism for criminalizing mental illness, an alternative to adequate voluntary services, or a convenient tool for managing people whom other systems find difficult to serve.
Nor should AOT be understood as protecting society from people with mental illness. We should aspire to communities that accept mental illness as part of the human experience, surround rather than isolate people experiencing it, support families, and understand recovery as something that occurs within relationships and communities.
For the relatively small number of people for whom AOT is appropriate, New York assumes responsibilities of its own. If the state uses its authority to require an individual to participate in treatment, it must be equally accountable for making that treatment available.
That principle is both simple and complicated. It means a properly funded and managed AOT program with access to clinicians, appropriate services, oversight, continuity, and good discharge planning. Recent New York State Comptroller audits identified shortcomings in AOT oversight, including delayed investigations, lapses in services, and weaknesses in monitoring. Accountability cannot run in only one direction. We should ask not only whether an individual complied with treatment, but whether the treatment system complied with its responsibilities to the individual.
AOT Should Be a Step Forward
If someone remains caught in a cycle of hospitalization, judicial involvement, poorly coordinated discharge, and renewed instability, simply adding a court order has accomplished very little. A functioning AOT system should provide the oversight, clinical access, and continuity necessary to interrupt that cycle and create a pathway toward recovery.
Success should not be measured by indefinite compliance with an AOT order. Success is a person thriving without AOT while retaining access to the services that helped them get there. That means continued access to appropriate voluntary treatment and supports rather than allowing services to disappear simply because the court order has ended. New York’s use of Enhanced Voluntary Agreements also provides a less restrictive pathway for some people who might otherwise be considered for AOT.
Recovery can also create an opportunity to plan for the future. Someone who has regained stability may wish to consider a psychiatric advance directive, documenting how they would want to be supported and treated during a future period when they may be less able to communicate those wishes.
AOT should be a bridge, not a destination. Its ultimate purpose should be greater autonomy, not compliance for compliance’s sake.
This cannot be an either/or debate because human beings do not exist in either/or categories. We exist across an infinite spectrum, and our needs and circumstances change throughout our lives.
Eliminating AOT would sell short the people for whom it may provide a necessary path toward recovery. Expanding it indiscriminately creates a different danger: abuse, entanglement with criminal justice, or use as a substitute for services people should have been able to access voluntarily.
The challenge is harder than choosing a side. New York must continue building robust voluntary services long before AOT becomes necessary. It must preserve AOT as a carefully limited tool for people whose needs cannot always be met through voluntary treatment alone. And when the state exercises the extraordinary authority to mandate treatment, it must accept an equally extraordinary responsibility to provide meaningful care.
Above all, we must never lose sight of the human being at the center. The measure of a humane system is not whether it can claim never to have used coercion. It is whether even its most difficult interventions remain directed toward recovery, dignity, connection, and ultimately the greatest possible return of autonomy to the person.
Nathan McLaughlin is Executive Director of NAMI New York State. He can be reached at [email protected], and more information is available at naminys.org.
