SAMHSA’s “Assisted Outpatient Treatment” Is Still Civil Commitment

On January 15, the Substance Abuse and Mental Health Services Administration (SAMHSA) hosted a webinar to promote its program expanding “assisted outpatient treatment” (AOT)—a civil court procedure that’s essentially the psychiatric version of the jail-alternative programs seen in drug courts.

SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation is currently taking applications for a “learning collaborative” (LC) that will provide selected candidates with subject-matter experts and technical assistance to enhance existing AOT programs in their communities, or establish new ones. Policy Research Associates, a self-described “positive social change” organization, has held the multi-million dollar GAINS Center contract since the early 1990s. 

“This LC will support teams in identifying and engaging community partners that have frequent interaction with individuals who may be eligible for AOT and are at risk of criminal justice involvement, homelessness or repeated crisis contact,” the GAINS Center stated in a December 2025 announcement. “Teams selected for this LC will work intensively to assess how AOT is currently functioning within their local and state statute and determine optimal ways to use AOT as an option for diversion, including approaches that support pre-arrest referral to community resources.”

AOT programs primarily target unhoused people with a history of drug use and/or psychiatric symptoms who have been deemed noncompliant by medical authorities. This form of involuntary commitment has been described as “psychiatric probation.” It is yet another carceral health service that reinforces structural oppression.

Organizations selected to participate in the taxpayer-funded LC will be mentored to improve their capacity to legally snatch vulnerable and marginalized people off the streets. They will skill up in coercing unhoused neighbors into civil court systems that siphon scarce resources from community-based services like permanent supportive housing.

“I thought [AOT] was involuntary at first, but then I quickly realized that it was super beneficial,” AOT program evaluator Dr. Cindy Gipson said during the opening presentation for the GAINS Center webinar.

Involuntary commitment is a cornerstone of President Donald Trump’s law-and-order approach to street homelessness, drug use and psychiatric disability. This was made clear in a July 2025 executive order and echoed in SAMHSA’s revised strategic priorities unveiled a few months later.

The practice emerged in the 1980s to correct what a number of medical authorities, cops and caregivers viewed as a pendulum that had swung just a little too far towards disabled people’s civil rights. They declared that deinstitutionalization—the movement to replace large hospital-based psychiatric treatment with smaller programs at community clinics—had failed, even though it has still never been fully implemented; JFK’s vision of community care was killed by Reaganomics. 

In the late 1990s, the Treatment Advocacy Center, aligned ideologically with right-wing think tanks like the Heritage Foundation and Manhattan Institute, began to exploit rare, high-profile murders committed by people with psychiatric diagnoses to sell their model involuntary outpatient commitment legislation to states. They rebranded the process as AOT, to make it sound more innocuous to policymakers.

Mainstream media outlets have repeated this propaganda, stoking fear and reinforcing false claims about people with “untreated serious mental illness” so that involuntary commitment has gained bipartisan support. 

Today, 48 states and the District of Columbia have involuntary outpatient commitment laws; only Massachusetts and Connecticut remain holdouts. However, many jurisdictions, such as Maryland where an AOT program was enacted in 2024, have struggled to implement these laws due to lack of funding or other structural hurdles.

In 2016, the 21st Century Cures Act established federal support in the form of the Assisted Outpatient Treatment Grant Program. Over the past decade, this program has funneled nearly $150 million to dozens of grantees to build out their courts and coercive systems.

While the Cures Act emphasized evidence-based practices, the evidence at large shows coerced and involuntary treatment to be ineffective at best, and harmful at worst. Supporting claims are often based on observational studies rather than more rigorous forms of research like randomized controlled trials—which have generally indicated that any benefits come from the expanded access to services and care, not from a court order. Research has also found consistent racism in the way AOT is implemented, with Black and Brown people being the overwhelming recipients of court orders in many jurisdictions.

In July 2025, the Government Accountability Office reported that the Department of Health and Human Services’ attempts to evaluate its own AOT program—whether it actually reduces hospitalizations, arrests or homelessness—had been “inconclusive,” citing fundamental flaws in how AOT is studied nationwide. GAO attributed the difficulties to small sample sizes, reliance on self-reported data and other “methodological challenges, many of which were inherent in the program.”

During the January 15 webinar Jennifer Honig, director of law and policy with Massachusetts’ Mental Health Legal Advisors’ Committee, asked in the chat if there would be any discussion of the GAO report’s findings. A Treatment Advocacy Center representative quickly chimed in to redirect the conversation to the “great outcomes” of other evaluations.

“I am really concerned about the idea that AOT is a less restrictive alternative to incarceration/hospitalization,” Honig told Filter. “I don’t see forcing powerful, mind-altering and life-affecting drugs on people to be less restrictive. It scares me and I would hope it would scare other people—even with all the other totally scary things going on in the US right now.”

Like jail-alternative programs for drug possession, AOT is marketed to the public as a compassionate, evidence-based public health intervention. In reality these programs are designed to disappear unhoused people while sidelining harm reduction, health care and housing justice policies that advocates have worked toward for decades.

The GAINS Center calls AOT an “early intervention.” It shouldn’t even be a last resort.

This article was originally published by Filter, an online magazine covering drug use, drug policy and human rights through a harm reduction lens. Follow Filter on Bluesky, X or Facebook, and sign up for its newsletter.