Pennsylvania's Allegheny County implementing involuntary outpatient mental health care services

Audio By Carbonatix

Allegheny County will use a controversial legal tool for involuntary mental health care in the community starting Jan. 1, according to a letter county officials sent Tuesday to the state’s Office of Mental Health and Substance Abuse Services. Called assisted outpatient treatment (AOT), it’s a law that no other Pennsylvania county has been able to successfully implement since state lawmakers voted for it in 2018.

The county developed its AOT plan based on research evidence, advice from local and national experts, and collaboration with partners across county government, wrote Erin Dalton, director of the county’s Department of Human Services, in the letter addressed to Deputy Secretary Jennifer Smith.

Dalton and other human services officials explained the county’s reasoning during an interview Tuesday with Pittsburgh’s Public Source.

“We’ve concluded that the risks of doing nothing are higher than the risk of trying this, and (I) think we’ve put a number of safeguards in place” to mitigate the harm that involuntary treatment can cause, she said.

Officials were motivated to act by “people’s calls for something at a lower threshold of risk than danger to self or others,” Dalton added, referring to the legal requirements for involuntary hospitalization, known as 302 commitments. In a paper published in July, a team of researchers — including one based at the Department of Human Services — established a causal link between 302s in Allegheny County and harm a person experiences after they’re discharged, including being charged with a violent crime and dying of suicide or overdose.

They don’t want “to wait and watch their loved ones decompensate in that way or wait for something more challenging to happen.”

The county will establish an advisory group to monitor implementation and review progress through 2026, according to the letter. Confirmed members include a former U.S. Attorney for the Western District of Pennsylvania, the director of a local court watch program, an unidentified psychiatrist, two academic experts, a disability rights attorney and the director of a major provider of shelter services in the county.

One member, Nev Jones, an associate professor of social work at the University of Pittsburgh and one of the fiercest critics of the county’s AOT plan, said she’s “not surprised” by the county’s decision to implement the law. She pointed to a nationwide shift in recent years toward strengthening involuntary mental health practices, compounded by an executive order issued by President Donald Trump in July that aims to institutionalize unhoused people who have mental illnesses, substance use disorders, or both.

The announcement follows a lengthy stakeholder engagement process, driven in part by a Public Source investigation this year of involuntary treatment here and in other jurisdictions. Almost exactly a year ago, the county quietly informed the state that it would implement the state’s AOT statute by Sept. 1. After an inquiry from Public Source in April, officials from the county’s Department of Human Services said the county was “still in exploration” and hadn’t made a decision yet.

At the time, news of the county’s interest in AOT inspired hope among the law’s advocates — including some family members of people with serious mental illness — who had long pushed for more forceful intervention to help those who resist treatment before they reach a crisis point.

And it triggered outcry from critics of AOT, including clinical and academic experts who said involuntary care can destroy a patient’s trust in the public mental health system and has serious implications for the civil rights and individual autonomy of some of the most vulnerable people in the county.

The county’s initial Sept. 1 deadline passed as it continued to engage with stakeholders and convened a working group that included officials across county government, including the Court of Common Pleas, the Office of the Public Defender — which will represent those facing AOT petitions — and others. It also consulted with officials from other jurisdictions with existing AOT programs, including those in California and New York state, which enacted the nation’s first AOT statute, Kendra’s Law, in 1999.

AOT is a legal mechanism for involuntarily treating people with serious mental illness without hospitalizing them. The law states “any responsible party” can file an AOT petition, which starts a civil court procedure. During a hearing, a judge may order a person to undergo treatment in the community, which typically includes psychiatric medication, but can also include therapy and other wraparound services. The statute bars courts from holding someone in contempt or issuing penalties for not following their treatment plan, which makes the law difficult to enforce. Some experts called it “toothless.”

In a May letter, nearly 80 county residents and experts from across the country urged County Executive Sara Innamorato and County Council members to “challenge” the Department of Human Services’ intention to implement AOT and demanded “robust transparency and accountability, including third-party evaluation … and engagement with those directly impacted” if implementation moved forward.

___

This story was originally published by Pittsburgh's Public Source and distributed through a partnership with The Associated Press.