What Is a Psychiatric Advance Directive?

A psychiatric advance directive is a legal document that outlines the care you do and do not wish to receive if you experience a severe mental health crisis and are unable to accurately communicate your treatment goals. If you are living with a serious mental illness, the psychiatric advance directive – also known as a mental health directive – allows you to communicate your treatment preferences while you are well and have the capacity to make informed decisions. Instructions may include information about:

• Which hospitals you wish to be treated at and which you want to avoid
• What medications have worked for you in the past
• What medications do not work or cause unmanageable side effects
• The names and contact information of friends, family and/or health care providers you trust
• The names of people you do not want to visit if you are hospitalized
• Consent to or refusal of electroconvulsive therapy (ECT)
• Possible causes of your mental health crisis (e.g. what triggered crises in the past)
• Ways to help you avoid hospitalization

As with any other healthcare directive, you may also include a healthcare power of attorney that designates who your surrogate decision maker or HEALTHCARE PROXY will be. That person will have the legal right to make decisions about your care if the healthcare team treating you determines that you lack the capacity to give informed consent. 

Notably, the instructions in a psychiatric advance directive DO NOT supersede the medical judgment of a treating physician and cannot prevent involuntary hospitalization if a qualified healthcare provider certifies that it is warranted. 

Goals of Psychiatric Advance Directives

The goal of a psychiatric advance directive is to bolster autonomy for people who live with a serious mental illness and facilitate shared decision making between those patients and the healthcare team. Historically, people who are experiencing an acute mental health crisis have been subjected to numerous coercive measures, including involuntary hospitalization, chemical restraint and treatment with various psychoactive drugs. And while these interventions are often necessary in the short term to keep the patient and those around them safe, their routine use has, in many cases, created an adversarial relationship between psychiatric patients and their caregivers. A psychiatric advance directive can help minimize the use of coercive measures and, according to several studies, improve patient outcomes such as symptom severity, feelings of empowerment, therapeutic alliance and rates of recovery. 

Creating a Psychiatric Advance Directive

As of this writing, most states in the U.S. allow for some form of advance directive for mental health care, although many only provide statutory forms for the appointment of a power of attorney for mental health care. Whenever possible, it’s best to use the forms provided by the state to help ensure that your directive will be honored when you are in crisis and cannot advocate for yourself. You will also need to comply with your state’s requirements around formalizing the document. For example, some states require the signatures of one or two witnesses while others mandate that the directive be notarized. To learn what is required in your state, refer to this state-by-state guide provided by the National Resource Center for Psychiatric Advance Directives. 

Regardless of whether your state has enacted a law around psychiatric advance directives, many experts in the field of mental health advocate for their use.  Thus, if your state does not provide a form that allows you to delineate your care preferences, you can design one yourself and attach it to your advance directive for healthcare or living will. This series of five short videos from the National Resource Center for Psychiatric Advance Directives provides step-by- step guidance on how to design a psychiatric advance directive that communicates your past experiences with mental health crises, as well as your personal preferences and treatment goals. 

Limitations of Psychiatric Advance Directives

Like all advance directives, psychiatric advance directives have operational limitations, such as the inability of first responders to locate the directive when a health crisis occurs. To minimize the chances of this occurring, make sure that your surrogate decision makers, your treating physician and your next of kin have a copy of your directive and that you keep those copies up to date. Unlike a general advance directive for healthcare, a psychiatric advance may need to be updated quite frequently as your mental health and treatment preferences evolve. 

Another major limitation of psychiatric advance directives is the inability of many persons with severe, chronic mental illness to understand the concept of a mental health directive or locate resources to assist them in completing one. This is especially true of patients who have had repeated interactions with the mental health care system and been subjected to multiple coercive interventions, such as involuntary hospitalization, restraint and seclusion. Having already lost faith in the system’s desire to preserve their autonomy, these patients may see little purpose in creating a document that will most likely be ignored. 

Still another limitation of psychiatric advance directives is the reluctance of care providers to honor them. When one considers that most interactions between the healthcare team and people experiencing a mental health crisis occur in the emergency room, this is hardly a surprise. Doctors and nurses confronted with a combative, hallucinating, or delusional patient are unlikely to take the time to look for a directive before instituting care. Nonetheless, once the crisis has been managed and the patient’s safety ensured, a psychiatric advance directive can help guide treatment decisions around future care. 

Summary

In summary, a psychiatric advance directive is a legal document that, if properly executed, may help persons living with a serious mental illness avoid involuntary hospitalizations and unwanted, ineffective or possibly harmful care. Although their use is not currently widespread, many policymakers and mental health providers advocate for their use. If you or a loved one suffers from a severe mental illness, it may be worthwhile to learn more about this potentially useful tool. Contact the National Resource Center for Psychiatric Advance Directives for additional information and helpful resources. 

If you or someone you know is in crisis, call or text 988 or chat at with 988lifeline.org. You may also contact SAMHSA’s National Helpline

24/7 to obtain free, confidential help.

• Call: 1-800-662-4357
• TTY: 1-800-487-4889
• Text your ZIP code to: 435748
• Visit SAMHSA’s National Helpline

Sources

“What Is an Example of Chemical Restraint?” MedicineNet. https://www.medicinenet.com/what_is_an_example_of_chemical_restraint/article.htm 

“A Practical Guide to Psychiatric Advance Directives”. SAMHSA. https://library.samhsa.gov/sites/default/files/psychiatric-advance-directives-pep19-pl-guide-4.pdf 

“The Therapeutic Alliance: The Fundamental Element of Psychotherapy”. Psychiatry Online. https://psychiatryonline.org/doi/10.1176/appi.focus.20180022 

“Psychiatric Advance Directives”. Mental Health America. https://mhanational.org/position-statements/psychiatric-advance-directives/ 

“Creating a Psychiatric Directive”. National Resource Center on Psychiatric Advance Directives. https://nrc-pad.org/creating-a-psychiatric-directive/