This study examined the long-term effects of completing a facilitated psychiatric advance directive on reducing coercive crisis interventions. We find that F-PAD completion was significantly associated with fewer coercive crisis interventions, lowering the adjusted odds by about half compared to those without PADs. The effect remained significant in the presence of appropriate statistical controls, including baseline history of CCIs and initial propensity to complete PADs.
These findings are important because they relate specifically to the core purpose for which PADs were designed. PADs have always been conceived as a legal mechanism for patients to retain some control over treatment decision making, rather than to have the state forcibly intervene. Underlying the design of this legal tool - and the specific legislative intent behind the statutes authorizing PADs - was the expectation that the advance directive would be of most value to patients during episodes of mental health crisis.
How might PADs actually accomplish reduction of coercion? In theory, PADs could prevent the use of CCIs in several ways. First, the experience of legally documenting one’s preferences and choices for future treatment could motivate the consumer to become more actively engaged in regular treatment; this could, in turn, help prevent the recurrence of mental health crises when CCIs might otherwise be applied.
Second, the socially-interactive process of preparing a PAD and discussing it with a clinician could help improve working alliance with the clinician. Indeed, our original study found that participants assigned to F-PADs had a statistically significant improvement in working alliance with their clinicians as compared to control group participants, and were more likely to report that their mental health treatment needs had been met (Swanson, 2006b
). If the clinician knows the client and is familiar with what the PAD document says, the clinician might also be in a good position to advocate for the consumer’s PAD preferences during a crisis and thus help the consumer avoid unwanted crisis interventions.
Third, PAD documents that authorize a proxy decision maker and agree in advance to specific future treatment could provide a legally sufficient substitute for contemporaneous consent to treatment when needed; this, too, in some cases could eliminate the need for an involuntary commitment order. In our study, PADs typically contained advance consent to hospitalization; indicated a preference for specific medications over others; and included advice to inpatient staff about how to help them avoid the use of physical restraints and seclusion during a future mental health crisis (Swanson et al., 2006a
Fourth, and finally, PADs typically provide useful information to clinicians - emergency contacts, treatment history, and interventions that have been helpful during past crises. Such information, on its face, may give clinicians a warrant to treat the patient without unduly invoking CCIs. In theory, a person with a PAD, or a family member, could also provide the PAD document to law enforcement officers who are transporting the patient or responding during a crisis. While designed to be invoked when the patient cannot communicate, it can also become in some situations a vehicle for communication between the patient and clinician. Insofar as the PAD gives the patient a “voice” and a sense of being respected - especially in situations when the patient is otherwise most powerless and vulnerable - the PAD may contribute directly to the quality of “procedural justice” which many previous studies have shown to be important in mitigating coercion (Tyler, 1992
; Lidz et al., 1998
; Watson & Angell, 2007
). If read and appropriately followed then competently-prepared PADs can help foster treatment alternatives that do not rely on CCIs.
There are several limitations to this study. First, insofar as there was a PAD effect on reducing CCIs, we are unable to distinguish between any direct effect of the legal document itself, and the perhaps indirect effect of the social process of producing the document. Also, the study analyses included only participants who were in treatment and willing to consent to research; therefore, these results may not be generalizable to all people with severe mental illness who might have completed PADs, had they been offered the chance to do so. Sample attrition was quite high in the second year of follow-up, with 24% dropping out between 12 and 24 months. PAD completers were significantly more like to be retained. However, having CCIs in the first wave did not predict subsequent attrition differentially in the PAD and no PAD groups. Moreover, the adjusted effect of PADs on CCIs was statistically significant even in the first wave considered alone, i.e., before substantial attrition.
Another limitation is that, because participants could not be randomly assigned to complete a PAD, the findings, like the results of any naturalistic observational study of an intervention, are subject to potential self-selection bias. Indeed, we found a significant negative bivariate association between the CCI outcome and baseline propensity to complete PADs. However, the potential for bias was substantially mitigated by controlling for PAD propensity in a multivariable regression analysis. The fact that PAD completion remained statistically significant in the final model, while PAD propensity became nonsignificant, lends credence to a causal interpretation of the results, rather than indicating a methodological artifact resulting from favorable selection bias.