Celebrating National Recovery Month through Awareness of Psychiatric Advance Directives

By Dr. Marvin Swartz

National Recovery Month is a national observance every September to educate Americans that persons with behavioral health disorders can live healthy and rewarding lives. Recovery month is also an opportunity to reflect on the struggle to achieve recovery and the critical value of treatment and other support services.

Unfortunately, some individuals with serious behavioral health disorders struggle to preserve their autonomy and avoid treatment they would not choose for themselves during mental health crises, in times when they cannot make competent choices about preferred treatment. During such times, the most common alternative for clinicians is initiating involuntary treatment whereby clinicians choose the treatment and often place individuals in crisis under temporary law enforcement custody. In retrospect, when recovered, many affected individuals deeply regret their loss of control and wish for a mechanism to preserve autonomy and direct treatment in a future crisis.

A critical alternative legal tool is available in every state in the United States through advance care planning, termed Psychiatric Advance Directives (PAD). A PAD is a competently prepared legal document – like a living will – outlining a person’s future treatment preferences to be implemented during a crisis, ideally combined with the advocacy of a family member or friend who can serve as an authorized proxy decision-maker. PADs have been available in the U.S. for more than three decades and serve as a device for communication between the person with mental illness, a proxy decision-maker, and healthcare providers. In surveys of people with serious mental illness, roughly two-thirds or more say they would want a PAD if given assistance, and in intervention studies that proportion does complete a PAD when help is given. Individuals who complete PADs report the document faithfully represents their wishes, enhances their relationship with clinicians and helps avoid involuntary care including often fraught interactions with law enforcement.

Much work is needed to raise public awareness of these legal tools. Faculty from the Wilson Center for Science and Justice lead a coalition of advocates for PADs and sponsor a comprehensive information resource at the National Resource Center for Psychiatric Advance Directive. The Resource Center details statutes enabling PADs in all U.S. states, provides public education and training to interested stakeholders and serves as a repository for legal developments.

A period of recovery from a behavioral health crisis is an ideal time to reflect on the course forward. PADs are a critical opportunity to leverage a novel legal tool to make a person’s choice known and respected.

Dr. Marvin Swartz is a professor in Psychiatry and Behavioral Sciences in the Duke School of Medicine and a faculty member of the Wilson Center for Science and Justice.