Advanced Directive Part 3

Positive changes have occurred in the delivery of mental health services since the implementation of Community Support Services. Depending your locality or State, these changes may include:

The introduction of rehabilitation and recovery approaches to services to persons with mental illnesses;
Enabling providers to deliver a range of crisis services;
Providing intensive services, such as Assertive Community Treatment teams;
Providing environments in which consumers of mental health services are participants in their treatment and in the design of treatment and alternative treatment services;
Creating opportunities for consumers, providers, and family members of consumers to work together on all levels--from improving the mental health treatment system to creating an individualized treatment plan.

A major purpose of these changes has been to improve the service delivery system, simultaneously improving the level at which consumers are empowered to direct their own treatment.

Empowerment and cooperation breaks down when involuntary care--also known as the commitment process--is required. Mental health professionals and representatives of the Court take over where a team--led by the consumer--once made decisions. This tends to create a situation in which the most important decisions about treatment--the most intensive treatment the consumer will have--omit the consumer in the decision-making process.

Consumers report they live in fear of the commitment process. It generally represents a total loss of control of where they will be, what will happen to them, who provides treatment, and where that treatment will be provided.

Providers also dislike the commitment process. It is replete with bureaucratic and legalistic procedures. Providers are required to testify to dangerousness, offer opinions that no less restrictive treatment is possible, and omit opportunities for coordinated, client-focused treatment.

In a similar manner, family members of the consumer feel helpless. They are often the petitioners to commit an individual with a mental illness. They watch--helpless--as the health system, the consumer, and the family are left behind and replaced by bureaucracy, Courts, and law enforcement.

The commitment process is necessary, some would argue, because people with mental illnesses sometimes get to a point where someone else must direct their care. The person with a mental illness lacks decisional capacity to make a treatment choice. Others--the Court and mental health professionals--must decide what treatment is necessary.

Commitment is a necessary approach to meeting the treatment needs of persons who lack the capacity to make a decision about treatment. It is designed--and typically applied--to assure protection of the person with a mental illness and/or protection of the community. It also circumvents or eliminates consumer empowerment and the consumer's opportunity to direct treatment.

This toolkit provides information for an alternative: an advance psychiatric directive which provides information on how psychiatric crises an individual may have should be treated. The advance psychiatric directive is written and shared prior to a crisis.

Commitment is typically about dangerousness. It is not usually possible to commit an individual without two conditions: (1) the individual has a mental illness and (2) because of the mental illness, the individual is dangerous to self or others. In most States, an individual may not be committed solely because she or he has a mental illness.

Dangerousness may be related to control. Dangerousness, and the ability to control our behavior, can be seen as a continuum between self-control and anger, not unlike a teeter-totter. When a person's confidence, ego-functioning and self-esteem is high, the potential of violent behavior (toward oneself or toward others) is low (see Figure 1 ⁽¹⁾ ) . An individual can handle most situations without becoming angry enough to consider or engage in violence; information is processed and actions are taken to prevent anger and/or violence.


¹ Thanks to Jim Terry, Potomac Highlands Guild, WV for this illustration		² Thanks to Jim Terry, Potomac Highlands Guild, WV for this illustration

If this combined decrease in self-control and increase in potential for violence is accompanied with mental illness, a person is generally deemed committable. There are services and approaches to services which can prevent such loss of control that commitment is necessary--or can prevent involuntary treatment even when it may be indicated. Most of these services are predicated on principles of education, right to treatment, and informed consent. ^{See Figure 2}

Consumers, family members, and providers are aware that programs and services such as Assertive Community Treatment, rehabilitation and recovery approaches, and 24-hour crisis services can prevent--or, at a minimum, ameliorate crisis situations. Interventions are provided at a time when an individual is experiencing, or beginning to experience, feelings of low self control. ⁽³⁾

Research into outcomes of mobile crisis teams ⁽⁴⁾ shows that most crises can be handled through negotiation and by restoring an individual's self-esteem and confidence. The crisis worker becomes, in effect, a mediator between the person in crisis and that individual's environment.

While education, informed consent, right to treatment in the least restrictive environment, mediation-style crisis intervention, and recovery approaches may offer opportunity to prevent crises and/or alleviate the crisis, some individuals may still reject intervention. Frequently, this rejection is based on not having designed the intervention.

This does not change the potential negative impact of commitment on an individual. "Once diagnosed with a mental illness, people are at risk of losing their civil rights based on inadequate and/or inappropriate consideration... Under the Fourteenth Amendment, no person may be deprived of life, liberty or property without due process of law...However, rights (and) due process are frequently comprised in the case of mental patients." ⁽⁵⁾ Any likelihood of commitment should be prevented whenever possible and unless involuntary treatment is absolutely necessary--whether due process is offered or not.

There is an opportunity to use an alternative to the commitment process through a consumer's pre-designed crisis intervention approach. Most State laws on advance directives enable individuals to specify treatment(s) they desire in the event their illness makes them incapable of exercising choice. That is, a person may write an advance directive which specifies help they want and desire when their mental illness reaches a crisis point they cannot control.

The existence of an advance directive does not preclude the use of commitment procedures. An advance directive may place an individual and significant others in the same position as Ulysses who changed his mind about being strapped to the mast of his ship to prevent danger. Ulysses was aware of the danger presented by the sirens near some rocks. In order to steer his ship through the narrow pass, he ordered his crew to plug their ears with wax and to tie him to the ship. Tempted by the sirens, he ordered a reversal of his previous orders.

An advance directive is much like a Ulysses decision. People who meet the criteria for commitment (have a mental illness and are dangerous to self or others)-- and who refuse to enter into treatment as prescribed in an advance directive--would be subject to commitment even with an advance directive. Willingness to accept treatment according to an advance directive may defer or render as unnecessary the commitment process.

The existence of an advance directive may render unnecessary the initiation of the commitment process-- with or without due process. Even when an individual refuses to comply with her or his advance directive, however, the advance directive may be used during the commitment hearing to decide treatment type, duration, and place. When an advance directive exists, the Court may use that information to determine what a person might have wanted and/or did not want.

An advance directive may make it unnecessary for commitment procedures to commence.� However, if a person refuses implementation of the advance directive, has a mental illness, and is dangerous to self or others, commitment may be instituted.

The content of an advance directive may be as simple or as complicated as the individual desires. In its simplest form, an advance directive indicates what treatment should be provided under what circumstances.

A more complicated advance directive would describe the place treatment is to be provided, who (or what agency) should provide it, what treatments cannot be provided, and who should authorize treatment(s).

The focus of the advance directive is to identify the circumstances which must exist for the directive to take effect. If these circumstances exist (typically as determined by the consumer and/or by the person designated by the consumer), then the specified treatment(s) would be implemented.

The advance directive is written by the consumer when he or she is not in crisis and is competent to write such a directive. It is signed, witnessed, and distributed to persons who may be involved in decisions about treatment.

The pages which follow are "toolkits" for creating or encouraging the creation of advance directives. A total of three toolkits are provided--one each for consumers, family members, and providers. It is essential that family members and providers remember that an advance directive may be written and signed only by a consumer. The toolkits for these segments of importance to consumers' lives are provided only for understanding the purpose and function of advance directives.

Advance directives must be written and signed by consumers of mental health services.� Family members and providers need to understand the nature of the advance directive, the possibilities of this approach, and the strength that comes to a consumer who prepares an advance directive.

³ Best Practices in Community-based Mental Health Services for Adult , Jack Stringfellow, West Virginia.� Unpublished monograph for study for West Virginia's Managed Behavioral Health Care System

⁴ Unpublished information collected by Roger Lohmann, Ph.D. Research conducted at Valley Comprehensive Community Mental Health Center, Morgantown, West Virginia.

⁵ Parrish, Jacqueline.�"Involuntary Use of Interventions: Pros and Cons" Innovations & Research 1 (1994): 15-22

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Thursday, March 18, 2010
WV - DHHR - BHHF	Last updated: Thursday, February 02, 2006