By Anna Scheyett, MSW, LCSW, CASWCM

People with serious mental illnesses such as bipolar disorder or schizophrenia often experience crises as part of their disorder. Because of their psychiatric symptoms during these crises they are often unable to talk about the treatment they would prefer.  They may experience involuntary and forced treatment instead.  Many people with a serious mental illness describe experiencing a crisis as a frightening time. They may feel as though they have no control over their situation. They may also feel they are being forced to do something they do not want to do. A Psychiatric Advance Directive or PAD is a tool that can help people experiencing a crisis have more control over their care .

What Is a PAD?

A PAD is a legal document that allows individuals with serious mental illnesses, when capable, to make a written record of their wishes for care. PADS also to communicate relevant information regarding their condition. During times of crisis when people may lose the ability to make mental health decisions, the PAD “speaks for them.” Their wishes can be noted and followed.

What Can Be Included in a PAD?

• PADs may include a description of signs of relapse.
• They may document that an individual accepts or refuses certain medications or other treatments such as electroconvulsive therapy.
• PADs may also provide information about things individual wants to happen if he or she is hospitalized (such as contacting a family member, caring for a pet).
• PADs may document a person’s advance informed consent for hospitalization.
• In addition, PADs may identify a surrogate healthcare decision maker for the individual.

Making Changes to a PAD

• PADs may only be made or changed when an individual is competent and capable of making mental healthcare decisions. PADs go into effect only when the individual has lost this capacity.
• During times of incapacity, the individual may not change the PAD in any way.
• When the PAD is in use, mental health providers are legally required to follow the individual’s preferences unless the request is dangerous, the service asked for is unavailable, or the request goes against community standards of care.
• Some form of specific PAD law exists in twenty states in the United States. Other states allow medical advance directives to include psychiatric requests as well.

Benefits of a PAD

During times of crisis, using a PAD may be of great benefit to consumers. With a PAD individuals are able to continue to have their choices honored during a time of incapacity. They will receive treatments they know from experience are most effective and they have a say in their care.

People may benefit from the process of creating a PAD particularly when done in collaboration with providers, such as social workers, and relevant caring others. During the process of making a PAD, people with mental illness have the chance to voice their experience living with a mental illness. This creates an opportunity to have that experience valued and used in the development of future plans.

Through the process of creating a PAD, people can more directly shape their treatment. They may have the option of talking with a social worker to learn more about treatments and make better informed treatment choices. This process leads to an increased sense of choice, of being listened to and respected. With a PAD people may be more willing to participate in treatment. This may increase their chances for recovery.

Similarly, a PAD can provide social workers with valuable psychosocial information regarding the individual in crisis. If clear instructions on crisis management and hospital diversion strategies are included, the PAD may decrease the number of hospital visits. Therefore, with a PAD there may be increased chances for recovery and less need of forced care.

Health Provider Concerns

Some mental health providers have said that consumers may not be able to complete an appropriate and informative PAD. Studies exploring the contents of PADs created by consumers found that the PAD was not used to refuse all treatment. Rather PADs were used to provide information about specific treatment requests, such as specific medications requested or refused, ways to de-escalate crises, and caring individuals to contact during crises. In addition, in a review of PAD content, it was found that 95 percent of the PADs consumers created were clinically appropriate and could be carried out.

Social Workers and PADs

Social workers can play an important role in helping consumers create and use a PAD. Social workers can support consumers’ use of PADs document by discussing PADs with them. Social workers can help them think through what they would wish during a crisis. Social workers can also make sure other mental health providers are aware of the PAD.

Resources

• Psychiatric Advance Directives – NAMI
• A Practical Guide to Psychiatric Advance Directives – SAMHSA
• Psychiatric Advance Directive – Mental Health America
• National Resource Center on Psychiatric Advance Directives

The opinions expressed in this article are those of the writer, and do not necessarily reflect those of the National Association of Social Workers or its members.