Assisted outpatient treatment orders and the therapeutic relationship in Assertive Community Treatment: a mixed-methods study

Background: A large proportion of clients served by Assertive Community Treatment (ACT) teams in New York City (NYC) are referred through “Assisted Outpatient Treatment” (AOT), which involves civil commitment to outpatient services. Research indicates that clients perceive AOT to be coercive, but it is unclear how this impacts the therapeutic relationships with ACT teams. We used mixed-methods to examine and compare perceptions of the therapeutic relationship and associated factors between ACT clients who were, and were not, referred through AOT. Method: Thirty persons receiving ACT services in NYC (15 AOT, 15 non-AOT) completed qualitative interviews about perceptions of treatment and referral, as well as measures of therapeutic alliance, procedural fairness, experienced coercion, shared decision-making, and self-stigma. Results: Quantitative findings revealed no differences in measures between AOT and non-AOT participants, with the exception being perception of “negative pressures” in the referral process, which was higher in the AOT group. However, qualitative findings were more mixed, with a notable subgroup of AOT-participants endorsing themes of paternalism and coercion in the referral and treatment decision-making process. Discussion: Findings indicate that the impact of AOT-referral on perceptions of ACT services is complex, and that AOT referrals impact treatment relationships in a subset of clients.