Advance Directives

To the Editor: As Srebnik and La Fond (1) indicated in their comprehensive review in the July 1999 issue, psychiatric advance directives hold great promise for ensuring consideration of an individual's preferences when he or she is unable to participate in decision making about treatment.

These documents are similar in principle to advance directives about end-of-life decisions. However, as the authors correctly note, a critical difference is the experience of the individual executing a psychiatric advance directive. Many people with serious mental illness endure recurrent episodes of acute disability and thus can offer quite explicit instructions, informed by their own past experience with psychiatric emergency care, about how they wish to be treated. Their experience often includes involuntary interventions such as civil commitment, forcibly administered medication, and seclusion and restraint.

As a result of these coercive procedures, many mental health consumers believe they have had no voice in the course of their treatment and have complied with treatment only in response to threats. Not surprisingly, they report that these procedures foster their repudiation of services that may be sorely needed.

Psychiatric advance directives could play an important role in reversing this pattern. By affording mental health consumers the opportunity to participate in treatment decisions—even during emergencies, when coercive practices have been most likely to intrude into treatment—the use of advance directives can allow mental health care providers to demonstrate that they value consumers' views and respect their choices. In so doing, mental health systems may begin to reverse the consumer antagonism that now contributes to the revolving door of the psychiatric hospital.

To help mental health consumers gain access to treatment on their own terms and, ultimately, to avert the negative consequences of dropout from treatment, the Bazelon Center for Mental Health Law has developed a prototype mental health advance directive, which is available on the Internet at www.bazelon.org/advdir.html.

Dr. Bernstein is executive director of the Bazelon Center for Mental Health Law in Washington, D.C.