Encyclopedia of Psychology and Law

PAD facilitation helps overcome patient barriers to

completing PADs and may improve working alliance

and treatment engagement among people with severe

mental illness. The authors found that 61% of partici-

pants in the facilitated session completed an advance

directive or authorized a proxy decision maker, com-

pared with only 3% of control group participants. At

1-month follow-up, participants in the facilitated ses-

sion had a greater working alliance with their clini-

cians and were more likely than those in the control

group to report receivingthe mental health services

they believed they needed.

In another analysis from this clinical trial, the

authors systematically examined competence to com-

plete PADs, using a newly developed instrument that

evaluates patients’ understanding, appreciation, and

reasoning ability applied to PADs and the specific

treatment decisions contained in PADs. The authors

found that the majority of participants at baseline

scored above 50% of the highest possible point total

on this instrument. That people with mental illness are

generally able to understand, appreciate, and reason

adequately with respect to PADs is consistent with

prior research reaching the same conclusion.

The study also showed that the manualized PAD

facilitation significantly improved patients’ compe-

tence to complete PADs, as well as their capacity to

make reasonable treatment decisions within the

framework of a PAD. The facilitation intervention

increased PAD competence most dramatically for

patients with low cognitive functioning and limited

initial understanding of PADs.

Concluding Remarks

In sum, PADs were designed as legal instruments for

persons with mental illness to retain some control

over their treatment during periods of decisional inca-

pacity. In practice, PADs could yield other indirect

benefits, such as improving communication between

providers, patients, and family caregivers; enhancing

therapeutic alliance and treatment engagement; and

mobilizing clinical resources. Jointly, these influences

could work together to help avert psychiatric crises, as

well as to improve the management of such crises

when they do occur, without resorting to involuntary

commitment.

However, it may be necessary to provide resources

to assist persons with mental disorders in completing

PADs, configure information systems to make PADs

accessible, and educate clinicians about the potential

benefits and drawbacks of PADs and their legal obli-

gations regarding PAD compliance. The National

Resource Center on Psychiatric Advanced Directives

disseminates state-by-state information on PADs and

educational material to patients, family members, pol-

icymakers, and clinicians through its Web site. Such

steps could be critical to ensuring that these legal

instruments are implemented effectively in clinical

practice and that people with mental disorders are

afforded the opportunity to plan and participate in

their own mental health treatment.

Eric B. Elbogen, Jeffrey W. Swanson,

and Marvin S. Swartz

See alsoCapacity to Consent to Treatment; Civil

Commitment; Competency, Foundational and Decisional;

Mandated Community Treatment; Mental Health Law;

Proxy Decision Making

Further Readings

Appelbaum, P. S. (2004). Psychiatric advance directives and

the treatment of committed patients. Psychiatric Services,

55 (7), 751–752.

Elbogen, E. B., Swanson, J. W., Appelbaum, P., Swartz,

M. S., Ferron, J., & Van Dorn, R. A. (2007). Competence

to complete psychiatric advance directives: Effects of

facilitated decision making. Law and Human Behavior,

31,275–289.

Hargrave v. Vermont, 340 F.3d 27 (2nd Cir. 2003).

Srebnik, D., & La Fond, J. Q. (1999). Advance directives

for mental health treatment. Psychiatric Services,

50 (7), 919–925.

Swanson, J. W., McCrary, S. V., Swartz, M. S., Elbogen, E. B.,

& Van Dorn, R. (2006). Trumping psychiatric advance

directives: Ethical and legal considerations. Journal of

the American Academy of Psychiatry and the Law,

34 (3), 385–394.

Swanson, J. W., Swartz, M. S., Elbogen, E. B., Van Dorn,

R. A., Ferron, J., Wagner, H., et al. (2006). Facilitated

psychiatric advance directives: A randomized trial of an

intervention to foster advance treatment planning among

persons with severe mental illness. American Journal of

Psychiatry, 163(11), 1943–1951.

Web Sites

National Resource Center on Psychiatric Advanced

Directives: http://www.nrc-pad.org

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