Do Clients in AOT Programs Truly Feel “Satisfied” and “Empowered” by Being Forcibly Drugged? — A Critical Analysis of a Treatment Advocacy Center Report

Do Clients in AOT Programs Truly Feel “Satisfied” and “Empowered” by Being Forcibly Drugged?

A Critical Analysis of a 2023 Treatment Advocacy Center Report

by
Rob Wipond

 

This report is licensed under the Creative Commons (CC BY-NC) — anyone may freely use or adapt with attribution for non-commercial purposes. Click here to download a free PDF of this report (6 pages). Click here for an MS Word document version.

 

Overview – Highlights

Expansions to outpatient commitment, often called Assisted Outpatient Treatment (AOT), have been ongoing in most US states for two decades. Simultaneously, there has been resistance from people and organizations concerned about the human rights infringements of the court-ordered forced drugging which is a core aspect of AOT. Some studies have found that most AOT clients themselves dislike AOT and find it unhelpful.

In January of 2023, the Maryland-based Treatment Advocacy Center (TAC) released the report, “Measuring Experiences: An Evaluation of AOT Participant Satisfaction,” based on surveys of clients in AOT programs in six Ohio counties. In press releases and the report, TAC summarized their key findings in this way (Page 1 of the TAC Report):

• “AOT participants reported high levels of satisfaction and feelings of empowerment”
• “More than three-quarters of participants agreed that they were satisfied”
• “Most AOT participants felt they received benefits”

These robust endorsements by clients in AOT programs appear to be important, and TAC stated that they intend to use their survey design in other jurisdictions. However, the study was not peer-reviewed, and TAC is well-known for lobbying for expansions to AOT. So, an independent analysis is warranted. And examining the TAC survey and results more closely reveals very different findings:

• Participants were not randomly selected, but were personally chosen by AOT treatment teams themselves to complete the survey
• Most of TAC’s survey questions severely limited what participants were permitted to say about medications and the coercive medicating
• TAC dismissed certain answers as symptoms of “anosognosia” or “lack of insight”—but accepted as valid other answers from the same participants
• The survey participants were never actually asked about their feelings of either “satisfaction” or “empowerment” with the AOT program
• A majority of participants disliked the AOT program
• A large majority expressed strong dislike for the coerciveness of AOT
• A large majority disliked the program so much that they did not want to ever participate in AOT again, even if they themselves believed they needed help

Each of these points is addressed in more detail on the following pages. In all, TAC’s own data showed that, even among highly medication-compliant clients personally chosen by AOT staff to participate in the survey, the majority disliked the coercion so much that they did not want to ever again be in an AOT program.

 

Introduction

AOT is generally presented to the public and legislators as a program of care and help rather than forceful policing. Therefore, the main controversy surrounding AOT has always centered on whether people benefit from the program’s court-ordered forced drugging with psychotropics, or instead benefit only from the free housing and voluntary supports and services that are sometimes provided alongside. Consequently, obtaining the opinions of patients about, separately, the involuntary versus voluntary aspects of AOT is essential to improving understanding of AOT’s impacts.

However, TAC’s survey questions, survey implementation, and data analysis appeared to be designed to avoid revealing AOT clients’ opinions about the involuntary aspects of the program, while maximizing the clients’ expressions of overall positive feelings.

 

Findings

1) The study group was highly medication compliant and unrepresentative of most people subjected to AOT court orders.

Participants in the survey were not selected randomly—AOT treatment teams chose which of their clients were invited to participate. AOT teams also administered the survey, and clients were informed it was a TAC survey. (Page 7) This created an environment that would likely lead to a strong bias towards including clients who were relatively compliant, had positive feelings about TAC, and had positive relationships with their AOT treatment teams. And the data shows this is indeed what happened.

About 40% of eligible AOT clients refused to participate in the survey, and their reasons for refusing were not reported by TAC. However, TAC acknowledged “it may have been the case that those who declined to participate were less likely to be satisfied with the program.” Even among those clients who did participate, TAC acknowledged, some might have understandably “felt uncomfortable sharing negative thoughts about the [AOT] program” with their AOT treatment teams. (Page 22)

Of the AOT clients who did participate in the survey, more than half described themselves as generally having in the past voluntarily taken medications, and in future intending to voluntarily take medications. (Pages 18 and 19) A large majority, 65%, indicated that they themselves, and not their treatment team, were currently controlling their treatments. (Page 21)

Since most people are court-ordered to enter AOT precisely to compel medication compliance against their will, these responses indicate that the AOT clients chosen to complete the survey tended to be highly medication compliant and not representative of most AOT clients.

 

2) TAC chose to dismiss certain answers from participants, but not other answers, as symptoms of anosognosia and mental illness.

TAC acknowledged the unusually high self-reported rate of medication compliance among the survey participants that was atypical of AOT clients. (Page 23) TAC also noted that 32% of the survey participants appeared to be ineligible to complete the survey at all because they reported that they hadn’t been in the AOT program long enough to develop an informed view. (Pages 5, 10)

However, TAC did not on the basis of these findings conclude that one-third of the survey responses were invalid while the majority of survey participants were unrepresentative of typical AOT clients. Instead, TAC explained that “people with severe mental illness” often suffer from “anosognosia” or “lack of insight” and “often have issues with memory and cognition that can affect the accuracy of responses as well as the extent of comprehension of questions being asked.” (Page 23) Essentially, when participant answers seemingly did not fit TAC’s preferred narrative, TAC selectively dismissed participants’ answers to some survey questions as “symptoms” of anosognosia and mental illness, but reported other answers by these same participants as completely trustworthy and valid.

 

3) The questions in TAC’s survey severely limited the possible answers that could be given, and avoided asking participants their feelings about coercion.

The TAC-designed survey had 41 questions, of which most were either multiple choice or statements graded on a Likert scale of agree/disagree. (Pages 5, 6) There were only four open-ended questions for which participants could express their answers freely. This format severely limited what issues participants could address, and what possible answers they could select.

The vast majority of TAC’s survey questions asked participants about their “overall” opinions on “the AOT program” as a whole, and did not permit participants to comment separately on the voluntary versus involuntary aspects of AOT. Consequently, the answers to most of TAC’s survey questions provided no information at all about the primary public controversy surrounding AOT and the most important research question: Participants’ perspectives on the coercive aspects of AOT as distinct from the voluntary services. Deep in the report, TAC acknowledged that, in future, researching “participant perception of coerciveness may be useful.” (Page 22)

 

4) Survey participants were actually never asked about their feelings of “satisfaction” or “empowerment” with AOT.

TAC’s report suggests 18 times that most participants felt “empowered” by or “empowerment” from the AOT program, and suggests 181 times that participants experienced “satisfaction” or were “satisfied.” Yet, none of the questions that survey participants were asked actually included the words “empowered,” “empowerment,” or “satisfaction.”

Instead, for example, if participants merely indicated that they’d been informed of their legal rights, felt “somewhat” comfortable speaking in court, and felt “somewhat” comfortable asking their treatment team for medical advice, TAC framed these answers as feelings of “empowerment.” (Page 6)

Only two questions asked participants what they felt “satisfied” about: How often they met with court staff or met with their treatment team. (Pages 31, 32) Participant assertions that they’d met enough times with court staff and treatment teams were framed by TAC as evidence that participants felt “satisfied and empowered” by the courts and treatment teams. (Page 15) Yet, these answers could easily indicate negative rather than positive feelings about AOT; that is, participants could have been reporting feeling “satisfied” that they weren’t compelled to meet more often with court staff and treatment teams. Indeed, this latter interpretation aligns with evidence in response to other questions that a large percentage of participants disliked the coercive requirements to attend meetings and appointments. (Page 17)

 

5) The TAC survey did not ask participants their feelings about adverse effects of psychotropic medications that they were being coerced to take.

Other surveys have found that, when asked about it, people will often say that they refused psychiatric treatment because they found the adverse effects of psychotropic medications too distressing. TAC’s survey asked participants why they’d declined treatment in the past, and offered participants nine possible multiple-choice answers—none of which specifically mentioned adverse effects from psychotropic drugs. Similarly, participants were given nine possible multiple-choice answers for why they might not continue with treatment in future—none of which specifically mentioned adverse effects from psychotropic drugs.

 

6) Participants did not feel AOT helped their mental health or well-being.

One question in TAC’s survey asked participants if they agreed or disagreed with the statement, “Overall, the AOT court order helps me get and stay well.” TAC’s report did not reveal how participants responded to that question. However, tellingly, in response to an open-ended question about what they liked about AOT, only 20% of participants said that the AOT program contributed to improving their overall well-being, health, or mental health. (Page 17)

 

7) The majority of participants disliked the coerciveness in the AOT program.

In response to an open-ended question about what they liked least about AOT, the majority of participants, 61%, expressed that they disliked the coercion. (Page 17) Participants described disliking “the need to take medications,” “the need to attend appointments” with treatment providers and others, and the consequences of failing to be compliant with these requirements, such as “arrest” and incarceration.

 

8) The majority of participants disliked the entire AOT program.

Half of participants said they felt “angry” and “disrespected” about being subjected to a court order. (Page 14) Overall, the participants disliked AOT so much that 65% of participants said that, even if they themselves in future felt they “needed” AOT, they still did not want to be in an AOT program ever again. (Page 20)

 

Conclusion

The TAC survey appears to have been designed specifically to avoid revealing participants’ true feelings about the coercive aspects of AOT. In any case, on the whole, TAC’s survey ultimately showed that even the majority of people who tended to be voluntarily medication-compliant and have good relationships with treatment teams still disliked the involuntary, coercive nature of AOT. And the majority of these people disliked it so much that they expressed willingness, in future, to give up all of the accompanying voluntary services to avoid AOT.

 

 

This report is licensed under the Creative Commons (CC BY-NC) — anyone may freely use or adapt with attribution for non-commercial purposes. Click here to download a free PDF of this report (6 pages). Click here for an MS Word document version.