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Psychiatric Advance Directive (PAD): Discuss With Your Therapist and Loved Ones

Living with a mental illness can be challenging, however, with insight and proper interventions we can regain control of our lives, dignity, and independence faster by planning ahead. Over the course of 11 years in recovery from schizophrenia I was hospitalized twice;  at age 20, and age 31. I was single during my first hospitalization. However, I had much at risk during my second hospitalization; my family, home, and thus, livelihood. My experience will further support both newly diagnosed peers, and fellow peers already in recovery who can attest to the disruptions of crisis and hospitalization that may have been handled better had a post-crisis plan and intervention been in place.

From experience I learned an even greater lesson than 'take your medication.' The lesson I learned is simple, and not an innovative idea, but sadly overlooked across treatment planning and visits, which is to plan ahead and document it! The psychiatric advance directive (PAD) much like the advance directive, which is routinely utilized in all medical settings upon intake is a document that identifies decision-making preferences, delegated agents, and overall, interventions with instructions.

In fact, the National Alliance on Mental Illness (NAMI) defines the purpose of an psychiatric advance directive: “A PAD allows a person to be prepared if a mental health crisis prevents them from being able to make decisions. A PAD describes treatment preferences, or names a person to make treatment decisions, should the person with a mental health condition be unable to make decisions.” Moreover, NAMI's Peer-to-Peer Education Course identifies the psychiatric advance directive. Further, Mary Ellen Copeland's Wellness Recovery Action Plan (WRAP) details what the ideal psychiatric advance directive should include through its post-crisis planning workbook.

The psychiatric advance directive can be an empowering tool when utilized. First, let me elaborate on what is included in a psychiatric advance directive (PAD). The PAD may include, but not be limited to the following elements of documentation:
  • Delegation of the primary decision-maker whenever there is an unspecified demand that requires a decision to be made on behalf of the peer.
  • A list of preferred facilities and treatment centers or alternatives. Example: hospitals, respite center, and alternatives.
  • A list of medications, which are preferred.
  • A list of medications to avoid and reasons why.
  • Signs or symptoms that helps the people that intervene determine when to activate the peer's PAD.
  • Signs and indications that the peer is in a better place to regain independent decision-making and thus, minimize the guidance and direction from the delegated agent in PAD.
  • A list of supporters and delegated responsibilities. Example: who will contact the peer's employer, landlord, and review and pay bills, watch their home, and check the mail.
  • Contact information that specifies the treatment team (doctor and therapist, etc.), delegated agent (caregiver), and supporters (friends, family, etc.).
  • Signature page (notarized) within the peer's PAD.

Therefore, the psychiatric advance directive can be an empowering document that gives peers choices when established and discussed in advance during a time of wellness and clarity on preferences. The psychiatric advance directive will undoubtedly enable the peer to practice resiliency. After the crisis and hospitalization the peer can focus wholeheartedly on recuperating opposed to being over-stressed with losses and unnecessary problems that could have been minimized such as past due bills, poor communication with employers, disrupted academic coursework, and shift in expectations of attendance for children of peers, etc.

My advice is to talk to your therapist and only those individuals that will become a part of the psychiatric advance directive. Discussing your PAD with therapist and loved ones, caregivers, and supporters will assist in the development and effectiveness of the PAD. These discussions may best be started with the therapist, in order, to learn more about the PAD, how to discuss PAD with others, and to get support to complete and distribute PAD among those that need to know, only. Because it may be challenging finding a therapist one may seek one-on-one therapy online, which can enhance ease of discussion from the comfort of home.

Finally, here are some resources to gain more information about the psychiatric advance directive and online therapists, as well as additional information shared in this blog entry:

Let me know your thoughts on the need and benefits of implementation of a psychiatric advance directive for yourself or loved one. Anonymous responses welcomed! Thank you.

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